From the Guidelines
Chronic venous ulcers are best treated with a comprehensive approach focusing on compression therapy as the cornerstone of management, with a minimum pressure of 20 to 30 mm Hg recommended, and pressures of 30 to 40 mm Hg advised for more severe disease. Patients should receive multilayer compression bandaging or compression stockings providing 30-40 mmHg of pressure at the ankle, as this compression helps reduce edema, improves venous return, and creates an optimal environment for healing 1. The wound should be cleansed regularly with normal saline and covered with appropriate dressings such as hydrocolloids, foams, or alginates depending on the amount of exudate. Debridement of necrotic tissue is essential and can be performed using enzymatic agents like collagenase, autolytic methods with hydrogels, or sharp debridement for larger areas of necrosis. Infection should be treated with appropriate antibiotics based on culture results, typically for 1-2 weeks.
Key Considerations
- Pentoxifylline 400 mg three times daily can be added to improve microcirculation and enhance healing, although it may cause gastrointestinal side effects 1.
- Patients should elevate their legs above heart level when sitting or lying down and maintain regular walking exercise to activate the calf muscle pump.
- Addressing underlying venous hypertension through procedures like endovenous ablation or sclerotherapy may be necessary for long-term management.
- Adequate nutrition with sufficient protein intake and blood glucose control in diabetic patients is also crucial for optimal wound healing. Some studies suggest that wound care, including debridement and dressing, is also important for healing, but the optimal protocol for wound care is yet to be elucidated 1. This multifaceted approach addresses both the wound itself and the underlying venous insufficiency causing the ulceration.
From the Research
Treatment Options for Chronic Venous Ulcers
- Compression therapy is a cornerstone in the management of chronic venous ulcers (CVU) 2, 3, 4
- Debridement of the ulcer when necessary, and wound care are also essential components of CVU treatment 2
- Collagen and antimicrobial dressings can improve the proportion of ulcers healed compared with compression alone 2
- Acellular skin equivalents are not superior to compression, but cellular human skin equivalents can promote more rapid healing, particularly in patients with longstanding ulcers 2
- Surgical treatment of the superficial venous system can decrease the time to healing of CVUs compared with compression therapy alone, but does not increase the proportion of ulcers healed 2
- Endovascular and surgical techniques that minimize valvular reflux and relieve venous obstruction improve venous hemodynamics, promoting wound healing 3, 4
- Topical steroid creams may reduce inflammation, venous eczema, and pain in the short term, but they can be detrimental in the long run 3
- Apligraf (a living, bilayered, cell-based product) in conjunction with compression therapy was noted to be more effective in healing venous leg ulcerations, when compared with treatment with compression therapy and zinc paste 3
- Vulnamin(®), a novel dressing in the form of a metal cellulose gel containing amino acids and hyaluronic acid, and elastic compressive bandages have been shown to be effective in treating chronic venous ulcers of the lower limbs 5
- Oral pentoxifylline has been shown to be more effective than placebo or no therapy in improving and healing venous leg ulcers (VLUs) when used with compression therapy or alone 6
Factors Affecting Treatment Outcome
- Ulcer duration longer than three months, initial ulcer length of 10 cm or more, presence of lower limb arterial disease, advanced age, and elevated body mass index are poor prognostic signs for healing 4
- Risk factors for the development of venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis, and venous reflux in deep veins 4
Additional Considerations
- Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures 4
- Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates 4
- Nutritional supplementation has not been clearly shown to prevent or manage chronic ulcers 6
- Pain management should start with topical drugs, and systemic drugs should be considered when pain is not managed with topical drugs 6