venous leg ulcers

see also:

• venous insufficiency of the leg
• DVT and post-thrombotic syndrome (PTS)
• the diabetic foot - infection or foot ulcers
• WH policy - Moisture Associated Skin Lesions: Incontinence Associated Dermatitis (doc) - intranet only
• Western Health Chronic Wound Clinic Referral form - internet accessible for GPs
  • adults with problematic or complicated open wounds > 4wks duration who reside in the WH catchment
  • referrals require form to be faxed

• venous leg ulcers are common chronic ulcers arising mainly on the shins of the elderly who have venous insufficiency of the leg usually due to varicose veins or post-thrombotic syndrome following DVT.
• most chronic ulcers are colonized with multi-resistant organisms and thus antibiotics have a limited role in Mx
• compression stockings help prevent recurrence of leg ulcers
  • in one study, recurrence of ulcers was 16% in those who complied, and 100% in those who did not comply with stockings!
  • C/I to stockings include acute cellulitis and mod./severe peripheral vascular disease (PVD or PAD)

• suspected sepsis / septicaemia or febrile neutropenia
• evidence of severe infection (see below) eg. T > 38degC
• suspected acute ischaemic leg - cold, pale, pulseless
• infection with co-morbidities (eg. CCF, diabetes, morbid obesity, etc)
• social issues that are likely to require admission to address

• no current on going care plan eg. a chronic wound clinic, district nurse, home support services, etc
• mild-mod infection requiring only 1-2 doses parenteral antibiotics
• work up to exclude occult sepsis

• patients suitable for SSU may be initially streamed to fast track for initial Mx whilst awaiting SSU bed

• exclude arterial cause - see peripheral vascular disease (PVD or PAD)
  • 20% of lower extremity ulcers are of mixed venous and arterial origin and therefore confirmation of a purely venous etiology for the ulceration is essential prior to initiating compression therapy.
  • clinical features which may suggest ischaemia include:
    • location over bony prominences
    • sharply demarcated punched out wounds
    • pale/grey wounds with minimal granulation tissue
    • minimal exudate
    • shiny, tight skin adjacent to wound, lack of local hair growth
    • pain may be aggravated by elevation rather than relieved
  • could it be a Martorell hypertensive ulcer (due to obliterative medial calcification of small arteries)?
    • uncommon, usually sited at supramalleolar region of the anterolateral leg or Achilles tendon
    • often bilateral
    • pulses are present and patient has hypertension and 60% are diabetic
    • initially erythemic patch, then painful ulcer with features of an ischaemic ulcer
• exclude acute cellulitis and Rx with systemic antibiotics if present
  • features of severe infection which may warrant Rx as per sepsis / septicaemia
    • T > 38degC, T < 36 degC
    • HR > 90/min
    • RR > 20/min
    • WCC > 12,000 or WCC < 4,000 or > 10% immature forms bands)
  • other clinical features which may suggest infection include:
    • fever
    • increasing erythema around wound > 2cm +/- induration (may be contact dermatitis though)
    • lymphangitis
    • increasing size of ulcer
    • increasing discharge from ulcer
    • wound odor
  • consider FBE, U&E, CRP, glucose +/- blood cultures, wound swab as indicated
• could it be a malignancy?
  • 2% of venous legs ulcers are said to have a SCC or BCC in its base
  • consider biopsy if not ischaemic and wound not healing after 3/12 of Rx
• exclude contact dermatitis
  • common and often difficult to detect, and often the cause of “bilateral cellulitis”
• general medical Mx of venous disease
  • see venous insufficiency of the leg such as aspirin, stockings, etc
• ulcer debridement
  • can be an important part of healing
• AVOID topical agents
  • ulcer healing rates are NOT improved with the use of most topical agents such as topical antiseptics, topical antibiotics, honey, debriding enzymes and growth factors
  • these increase risk of contact dermatitis
• dressings
  • dressings control exudate, maintain moisture balance, control odor, and help control pain
  • use of silver dressings was associated with significantly decreased odor and leakage
  • otherwise no good evidence to support one type of dressing over another, although certain dressings may be more appropriate for certain types of ulcers, for example, hydrogels and alginate dressings are highly absorbent and well suited to heavily exudative ulcers, while occlusive dressings speed reepithelialization, stimulate collagen synthesis, and create a hypoxic environment at the wound bed that encourages angiogenesis
• consider role of skin grafts
  • may have a role in those ulcers which fail to improve over 12 mths of care