From the Guidelines
The treatment of chronic venous ulcers should prioritize compression therapy with a minimum pressure of 20 to 30 mm Hg, and up to 30 to 40 mm Hg for more severe disease, as it has been shown to reduce edema and improve venous return 1. The cornerstone of treatment is compression therapy using multilayer bandages, compression stockings, or pneumatic compression devices.
- Key considerations for compression therapy include: + Using a minimum pressure of 20 to 30 mm Hg, and up to 30 to 40 mm Hg for more severe disease + Applying compression bandages with more force at the calf than the distal ankle (negative graduated compression bandage) for improved ejection fraction in refluxing vessels and higher extrinsic pressures + Ensuring proper fitting, education, and detailed instructions to encourage adherence
- Wound care should include: + Regular cleansing with normal saline + Debridement of necrotic tissue as needed + Application of appropriate dressings such as hydrocolloids, alginates, or foam dressings depending on wound characteristics and exudate levels
- Additional treatments may include: + Pentoxifylline 400 mg three times daily to improve healing by enhancing microcirculation, as shown in a meta-analysis of 11 trials 2 + Leg elevation above heart level for 30 minutes several times daily to reduce edema + Advanced therapies like skin substitutes or negative pressure wound therapy for recalcitrant ulcers + Surgical interventions such as endovenous ablation, sclerotherapy, or vein stripping for patients with significant venous reflux
- Patient education and support are crucial for long-term success and prevention of recurrence, including: + Compression compliance + Leg elevation + Weight management + Nutritional support with protein supplementation + Regular follow-up and adequate pain management 1, 3
From the Research
Treatment Options for Chronic Venous Ulcers
- Compression therapy is a widely accepted treatment for chronic venous ulcers, as it helps to improve blood flow and reduce swelling 4, 5, 6.
- Pentoxifylline, a drug that improves blood flow, has been shown to be an effective adjunct to compression therapy in treating venous ulcers 5, 7, 8.
- Exercise and dressings are also important components of treatment, as they can help to promote healing and prevent infection 4, 6.
- Tissue products, such as collagen and antimicrobial dressings, can also be used to improve healing rates 6.
- In some cases, surgical intervention may be necessary to correct superficial venous reflux and improve healing rates 4, 6.
Benefits and Risks of Treatment
- The use of pentoxifylline has been shown to decrease the time to complete wound healing and improve ulcer size 5, 7, 8.
- However, pentoxifylline can also cause adverse effects, such as gastrointestinal disturbances, although these are generally tolerated by patients 7, 8.
- Compression therapy can also cause skin irritation and other adverse effects, although these are generally mild 4, 6.
- Surgical intervention can also carry risks, such as infection and scarring, although these can be minimized with proper technique and post-operative care 4, 6.
Prognostic Factors and Referral to Specialist Care
- Poor prognostic signs for healing include 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 4.
- 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 can improve healing and decrease recurrence rates in patients with chronic venous ulcers 4, 6.