From the Guidelines
Treatment for chronic venous ulcers should prioritize compression therapy with a minimum pressure of 20 to 30 mm Hg, and 30 to 40 mm Hg for more severe disease, as it has been shown to reduce venous stasis and improve wound healing 1. The cornerstone of treatment is compression therapy using multilayer bandages, compression stockings, or pneumatic compression devices to reduce edema and improve venous return.
- Key aspects of compression therapy include:
- Using a minimum pressure of 20 to 30 mm Hg, and 30 to 40 mm Hg for more severe disease
- Applying compression bandages with higher pressures at the calf over the distal ankle for improved ejection fraction in refluxing vessels and higher extrinsic pressures
- Encouraging adherence with proper fitting, education, and detailed instructions
- Wound care includes:
- Regular cleansing with normal saline
- Debridement of necrotic tissue when necessary
- Application of appropriate dressings such as hydrocolloids, foams, or alginates depending on wound characteristics and exudate levels
- Infection should be treated with topical antimicrobials like silver-containing dressings or systemic antibiotics if cellulitis is present.
- Pentoxifylline 400 mg three times daily can be added to improve healing by enhancing microcirculation, as shown in a meta-analysis of 11 trials 1.
- Elevation of the affected limb above heart level when resting and regular exercise to activate the calf muscle pump are important adjunctive measures.
- For recalcitrant ulcers, advanced therapies like skin substitutes or negative pressure wound therapy may be considered.
- Surgical interventions such as endovenous ablation, sclerotherapy, or vein stripping might be necessary to address underlying venous insufficiency, with comparable long-term outcomes to surgical intervention for saphenous insufficiency 1.
- Proper nutrition with adequate protein intake and management of comorbidities like diabetes are essential for optimal healing.
- Patient education about long-term compression therapy is crucial as recurrence rates are high without continued compression after healing.
From the Research
Treatment Options for Chronic Venous Ulcers
- Compression therapy is the mainstay of treatment for chronic venous ulcers, as it helps to reduce venous hypertension and promote wound healing 2, 3, 4, 5.
- Surgical intervention, such as sclerotherapy and venous ablation, can be effective in treating chronic venous ulcers, especially in cases where compression therapy is not enough 2, 3, 5.
- Advanced wound care products, such as acellular skin equivalents and cellular human skin equivalents, can promote wound healing and improve outcomes 4, 5.
- Pentoxifylline, a medication that improves blood flow and reduces inflammation, can be used in conjunction with compression therapy to promote wound healing and reduce ulcer size 6.
- Debridement, or the removal of dead tissue, can be necessary to promote wound healing and prevent infection 2, 5.
Factors Affecting Treatment Outcomes
- The duration and size of the ulcer can affect treatment outcomes, with larger and longer-lasting ulcers being more challenging to treat 3, 5.
- The presence of underlying medical conditions, such as heart failure and hypertension, can impact treatment outcomes 2.
- Patient demographics, such as age and body mass index, can also affect treatment outcomes 3.
Comprehensive Care
- Comprehensive care for chronic venous ulcers includes compression therapy, local wound debridement, control of bioburden, wound moisture balance, and the possible use of advanced wound care products 2.
- Referral to a wound subspecialist may be necessary for ulcers that are large, of prolonged duration, or refractory to conservative measures 3.