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MANAGEMENT OF VENOUS ULCERS

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

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  1. Introduction
  2. Classification
  3. Risk Factors & Associated Factors
  4. Diagnosis
  5. Investigations
  6. Treatment
  7. Conclusion

Content

Wound Care Training Module - National Wound Care Committee

Content

Wound Care Training Module - National Wound Care Committee

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INTRODUCTION

  • Venous ulcer is the commonest cause of leg ulcer.
  • It contributes to a significant socio-economic disability in the population as it affects the quality of life.
  • It is due to presence of venous hypertension in the lower limbs.

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CLASSIFICATION

  • There are two major groups of venous ulcer, with different treatment options and outcomes.

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  1. Ulcer secondary to primary varicose veins
    • In this group of patients, treating the varicosities will usually result in ulcer healing.

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  • Ulcer secondary to deep venous incompetence
    • Post-phlebitic syndromes contribute to a big proportion of this group and treatment is aimed to improve healing rate and reducing recurrence of the ulcer.

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RISK FACTORS & ASSOCIATED FACTORS

  • Risk factors for chronic venous ulcer:
    • Varicose veins
    • Deep vein thrombosis
    • Chronic venous insufficiency
    • Poor calf muscle function
    • Obesity
    • History of leg injury
    • Family history

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RISK FACTORS & ASSOCIATED FACTORS

  • Associated factors:
    • Diabetes mellitus
    • Heart failure
    • Venous ulcer over the Gaiter's area
    • Hypertension Renal disease
    • Rheumatoid arthritis

Venous ulcer over the Gaiter's area

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DIAGNOSIS

  • Diagnosis of venous ulcer is made based on history and physical examination.

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History:

  1. Risk factors
    • Above listed risk factors should be identified 
  2. History of deep vein thrombosis
    • Documented or suggestive history of previous DVT
  3. Symptoms of chronic venous insufficiency
    • Calf heaviness after prolonged standing

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Examination:

  1. Examination of the ulcer/wound
    • Typical site: just above the medial malleolus – the Gaiter’s area.
    • Leg edema, thickening and hyperpigmentation (lipodermatosclerosis) of the surrounding skin.
  2. Varicose veins
    • May or may not be present. These may just be telengeactasia, spider veins or varicosities along the long or short saphenous veins
  3. Peripheral arterial pulses
    • Palpate and confirm distal pulses to exclude arterial disease

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INVESTIGATIONS

  • A duplex ultrasound scan is required in patients suspected to have ulcer secondary to deep venous incompetence 
    • To look for deep vein patency and incompetence
    • To identify sapheno-femoral or sapheno-popliteal junction incompetence
    • To identify and localize incompetent perforators

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TREATMENT

  • Leg elevation and compression bandaging are the most important components of treatment.
  • It is crucial to exclude peripheral arterial disease before commencing on compression therapy.

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  1. Elevation of the leg
    • Reduces leg edema and promote wound healing
    • Elevate higher than the heart level

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  • Graduated compression stockings and compression bandages
    • Multi-layer compression (4 layer or 2 layer) is used during the acute phase
    • Graduated compression stockings can be used once the wound is more dry

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  1. For local management of a venous ulcer refer to Wound Care Algorithm.

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  • In cases of venous ulcer secondary to primary varicose veins, patients should be referred for surgical intervention with high saphenous vein ligation once the acute phase and infection is under control.

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  1. Pharmacotherapy
    • Venotonic agents, e.g. Micronised flavinoids aids in the venous flow
    • Hemorheologic agents, e.g. Pentoxifylline

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  • Life-style modification to reduce rate of recurrence
    • Change of work
    • Weight reduction and dietary counseling

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CONCLUSION

  • Venous ulcer is one of the common causes of leg ulcer and it causes a significant socio-economic disability.
  • It is crucial to identify ulcers that are due to primary varicose veins for surgical intervention.
  • Otherwise, treatment involves a long-term management plan aimed to hasten healing and reduce recurrence.

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TAKE HOME MESSAGES

  • Leg elevation and compression therapy are two important components of treatment.
  • Important to differentiate between ulcer secondary to primary varicose veins or deep venous incompetence.
  • Need to exclude arterial disease before commencing treatment.

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REFERENCES

  • David Bergqvist, MD, PhD, Christina Lindholm, RN, PhD, and Olle Nelzén MD, PhD. Chronic leg ulcers: The impact of venousdisease. J Vasc Surg 1999;29:752-5.
  •  Blair SD, Wright DDI, Backhouse CM, Riddle E, McCollum CN. Sustained compression and healing of chronic venous ulcers. BMJ 1988;297:1159-61
  •  Maria T. Szewczyk et.al. Comparison of the effectiveness of compression stockings and layer compression systems in venous ulceration treatment. Arch Med Sci 2010; 6, 5: 793-799
  •  Michael S. Weingarten. State-of-the-Art Treatment of Chronic Venous Disease. Clinical Infectious Diseases 2001; 32:949–54
  •  Lyseng-Williamson KA Lyseng-Williamson KA, Perry CM. Micronised purified flavonoid fraction: a review of its use in chronic venous insufficiency, venous ulcers and haemorrhoids. Drugs. 2003;63(1):71-100

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THANK YOU

Wound Care Training Module - National Wound Care Committee