What is the best wound care for a venous ulcer?

Best Wound Care for Venous Ulcers

Compression therapy with 30-40 mmHg inelastic compression is the cornerstone of venous ulcer management, combined with sharp debridement, moisture-maintaining dressings, and treatment of underlying venous disease. 1

Compression Therapy: The Foundation

• Apply 30-40 mmHg inelastic compression for active venous ulcers, which is superior to elastic bandaging for wound healing 1
• Measure ankle-brachial index (ABI) before initiating compression to rule out arterial insufficiency 1
• For patients with ABI 0.6-0.9, reduce compression to 20-30 mmHg, which remains both safe and effective 1
• Velcro inelastic compression devices are as effective as multilayer bandages and may improve patient compliance 1
• Compression stockings are an acceptable alternative option 1

The evidence strongly supports compression as the "gold standard" for venous ulcer treatment, with systematic reviews demonstrating that chronic venous ulcers heal more quickly with compression compared to primary dressings alone 2. This is non-negotiable for venous ulcer management.

Wound Bed Preparation

Debridement Strategy

• Perform sharp debridement to remove hyperkeratotic rim, slough, necrotic tissue, and surrounding callus 3, 1
• Frequency should be determined by clinical need, typically at each dressing change for actively sloughy wounds 3
• Sharp debridement is preferred over enzymatic, ultrasonic, or surgical debridement based on expert consensus, despite limited high-quality evidence 2
• Surgical debridement in a sterile environment is not necessary if sharp debridement can be performed in the clinic setting 2

Dressing Selection

• Use basic wound dressings that absorb exudate and maintain a moist wound environment 3, 1
• Select dressings based on the lowest acquisition cost for your healthcare setting 2
• For necrotic ulcers: hydrogels or hydrocolloids for autolytic debridement 4
• For heavily exuding wounds: alginate or hydrofiber dressings 4
• For granulating wounds: polyurethane foams 4
• For epithelializing wounds: thin hydrocolloids or polyurethane films 4

Do not use antimicrobial or antibacterial dressings/ointments for wound healing purposes unless documented infection is present 3, 1. A Cochrane review found no advantage for specialized dressings over low-adherent dressings when used beneath compression 4.

Treatment of Underlying Venous Disease

• Obtain venous duplex ultrasonography to assess for reflux in perforating, superficial, and deep veins (reflux defined as >350ms in perforators, >500ms in calf veins, >1000ms in femoropopliteal veins) 1
• Endovenous ablation is first-line treatment for patients with symptomatic varicose veins and documented valvular reflux 1
• Consider iliac vein stenting for post-thrombotic iliac vein obstruction, particularly when large ulcers have decreased in size from prior superficial vein ablation but require additional intervention for complete healing 2, 1

Adjunctive Therapies for Refractory Ulcers

Only consider these after 4-6 weeks of optimized standard care (compression + debridement + basic dressings) has failed: 1

• Pentoxifylline 400 mg three times daily has moderate evidence for effectiveness over placebo 1
• Split-thickness skin grafting may be considered 1
• Sucrose-octasulfate impregnated dressing for non-infected ulcers (conditional recommendation) 3
• Negative pressure wound therapy for large, deep ulcers 4

Do not routinely use cellular skin substitutes as the IWGDF provides a conditional recommendation against their routine use due to lack of cost-effectiveness and moderate resource requirements 3.

Exercise and Maintenance

• Prescribe supervised exercise training consisting of leg strength training and aerobic activity for at least 6 months for patients who can tolerate it 2, 1
• Exercise improves calf muscle pump function and does not aggravate leg symptoms 2

Critical Pitfalls to Avoid

• Never apply full compression without measuring ABI first - you risk limb-threatening ischemia in patients with arterial disease 1
• Avoid antibacterial ointments for wound healing - they have no benefit and may delay healing 3
• Do not use expensive advanced therapies as first-line treatment - compression and basic wound care should be optimized first 2, 1
• Do not neglect treatment of underlying venous disease - wound care alone without addressing venous reflux leads to high recurrence rates 2, 1