From the Guidelines
Lower leg ulcers due to poor vascular flow should be treated with a comprehensive approach focusing on improving circulation and wound healing, with consideration of revascularization if toe pressure is <30 mmHg or TcpO2 <25 mmHg, as recommended by 1.
Key Considerations
- The primary goal is to restore direct flow to at least one of the foot arteries, preferably the artery that supplies the anatomical region of the wound, as stated in 1.
- Revascularization techniques should be selected based on individual factors, such as morphological distribution of PAD, availability of autogenous vein, and patient co-morbidities, as well as local expertise, as recommended by 1.
- Pharmacological treatments to improve perfusion have not been proven to be beneficial, according to 1.
- Efforts to reduce cardiovascular risk, such as cessation of smoking, control of hypertension and dyslipidemia, and use of aspirin or clopidogrel, are crucial, as emphasized in 1.
Treatment Approach
- Compression therapy using multilayer bandages or compression stockings (30-40 mmHg pressure) can help reduce edema and improve venous return, as seen in the example answer.
- The wound should be cleansed gently with normal saline and covered with appropriate dressings, such as hydrocolloids, alginates, or foam dressings, changed every 1-3 days depending on exudate levels.
- Elevation of the affected leg above heart level when sitting or lying down is crucial to reduce swelling and promote healing.
- For infection, topical antimicrobials like silver-containing dressings may be used, while systemic antibiotics, such as cephalexin 500mg four times daily for 7-14 days, are reserved for clinical signs of infection.
- Pain management with acetaminophen or NSAIDs may be necessary to ensure patient comfort.
- Regular debridement of necrotic tissue and nutritional support with adequate protein intake (1.2-1.5g/kg/day) and vitamin C supplementation (500mg daily) can enhance healing, as recommended in the example answer.
Revascularization
- Consider urgent vascular imaging and revascularization in patients with a foot ulcer in diabetes where the toe pressure is <30 mmHg or the TcPO2 <25 mmHg, as recommended by 1.
- Consider vascular imaging and revascularization in all patients with a foot ulcer in diabetes and PAD, irrespective of the results of bedside tests, when the ulcer does not improve within 6 weeks despite optimal management, as stated in 1.
- Surgical procedures, such as bypass surgery, can be effective in establishing in-line blood flow to the foot in patients with nonhealing wounds or gangrene, as recommended by 1.
From the FDA Drug Label
Pentoxifylline and its metabolites improve the flow properties of blood by decreasing its viscosity. In patients with chronic peripheral arterial disease, this increases blood flow to the affected microcirculation and enhances tissue oxygenation Pentoxifylline Extended-Release Tablets are indicated for the treatment of patients with intermittent claudication on the basis of chronic occlusive arterial disease of the limbs.
Treatment of lower leg ulcer due to poor vascular flow:
- Pentoxifylline may be beneficial in improving blood flow and tissue oxygenation in patients with chronic peripheral arterial disease, which can help in the healing of lower leg ulcers.
- The drug is indicated for the treatment of intermittent claudication, which is a symptom of poor vascular flow.
- However, it is essential to note that pentoxifylline is not intended to replace more definitive therapy, such as surgical bypass, or removal of arterial obstructions when treating peripheral vascular disease 2, 2.
From the Research
Lower Leg Ulcer Due to Poor Vascular Flow
- Lower leg ulcers due to poor vascular flow can be a challenging condition to treat, but several studies have investigated the use of pentoxifylline as a potential therapy 3, 4, 5, 6, 7.
- Pentoxifylline has been shown to improve blood flow and reduce blood viscosity, making it a potential adjunct to compression bandaging for treating venous ulcers 4, 5, 6.
- Studies have demonstrated that pentoxifylline is more effective than placebo in terms of complete ulcer healing or significant improvement, with a relative risk of 1.70 (95% CI 1.30 to 2.24) 5, 6.
- The use of pentoxifylline in combination with compression bandaging has been shown to be more effective than compression alone, with a relative risk of 1.56 (95% CI 1.14 to 2.13) 5, 6.
- Pentoxifylline may also be effective in the absence of compression, with a relative risk of 2.25 (95% CI 1.49 to 3.39) 5, 6.
- However, pentoxifylline has been associated with adverse effects, including gastrointestinal disturbances, which were reported in nearly three-quarters of cases 5, 6.
Mechanism of Action
- Pentoxifylline is thought to work by improving blood flow and reducing blood viscosity, which can help to deliver oxygen and nutrients to the affected area 3, 7.
- It may also help to reduce the deposition of fibrin and other proteins that can impede blood flow and wound healing 3.
Clinical Evidence
- Several studies have demonstrated the effectiveness of pentoxifylline in treating lower leg ulcers due to poor vascular flow, including a study published in the Journal of the American Osteopathic Association 3 and several reviews published in the Cochrane Database of Systematic Reviews 4, 5, 6.
- A study published in the Annals of Pharmacotherapy also discussed the use of pentoxifylline for diabetes-induced peripheral vascular disease, including diabetic foot ulcers 7.