Venous Ulcer Treatment
The mainstay of treatment for venous ulcers is compression therapy, with a minimum pressure of 20-30 mmHg for most cases and 30-40 mmHg for more severe disease, as this has been shown to significantly improve healing rates compared to non-compression treatments. 1, 2
Initial Assessment and Diagnosis
- Duplex ultrasonography should be the first imaging assessment of the lower extremity venous system to evaluate direction of blood flow, venous reflux, and venous obstruction 1
- Measure ankle-brachial index prior to initiating compression therapy to rule out arterial insufficiency, as high compression may be contraindicated in mixed arterial-venous disease 2
- Reflux is defined as retrograde flow duration of >350 milliseconds in perforating veins, >500 milliseconds in superficial and deep calf veins, and >1,000 milliseconds in femoropopliteal veins 2
First-Line Treatment: Compression Therapy
- For active venous ulcers, inelastic compression of 30-40 mmHg is superior to elastic bandaging for wound healing 1
- For patients with ankle-brachial indices between 0.6-0.9, reduced compression of 20-30 mmHg is both safe and effective 2
- Compression options include multi-layer bandages, compression stockings, and Velcro inelastic compression devices (which are as effective as multi-layer bandages) 2
- Negative graduated compression bandages (higher pressure at calf over distal ankle) show improved ejection fraction in refluxing vessels compared to traditional graduated compression 1
Wound Care Management
- Maintain a moist wound environment to optimize healing 1
- Provide protective covering for the wound 1
- Control dermatitis around the wound 1
- Aggressively prevent and treat infection 1
- Debride necrotic tissue to promote healing, though optimal debridement protocol is not fully established 1
- Antibiotic dressings have shown no benefit for routine use 1
Pharmacological Treatment
- Pentoxifylline 400 mg three times daily is more effective than placebo for complete healing or significant improvement of ulcers (RR, 1.70; 95% CI, 1.30–2.24) 1
- Pentoxifylline plus compression is more effective than placebo plus compression (RR, 1.56; 95% CI, 1.14–2.13) 1
- Be aware that pentoxifylline may cause gastrointestinal side effects including nausea, indigestion, and diarrhea 1
Exercise Therapy
- A supervised exercise training program consisting of leg strength training and aerobic activity for at least 6 months is reasonable for patients who can tolerate it (Class IIa; Level of Evidence B) 1
- Exercise may improve calf muscle function and ejection of venous blood from the limb 1
Advanced Interventions for Refractory Ulcers
- Consider endovenous ablation for patients with documented valvular reflux in superficial veins 2
- For ulcers that fail to improve after 4-6 weeks of standard therapy, consider split-thickness skin grafting or cellular therapy 2
- Iliac vein stenting should be considered for post-thrombotic iliac vein obstruction, as it improves pain, swelling, and venous ulcer healing 1
- Surgical or endovascular procedures to remove or ablate incompetent superficial veins may be beneficial, though their role remains somewhat controversial 1
- Neovalve reconstruction may be considered as a surgical treatment for refractory venous ulcers 1
Monitoring and Prevention
- Regular follow-up is essential to monitor healing progress and adjust therapy as needed 2
- Continue compression therapy after ulcer healing to prevent recurrence 3
- Address modifiable risk factors such as obesity and physical inactivity 3