What topical treatment can be applied twice weekly to manage odor in a patient with a venous stasis ulcer on the right heel, significant serosanguineous drainage, and no signs or symptoms of infection, who is currently using an Unna boot?

Topical Odor Management for Venous Stasis Ulcer

For odor control in a venous stasis ulcer without infection, apply a cyclodextrin-containing hydrocolloid dressing (such as Exuderm OdorShield) or a charcoal-based dressing (such as Actisorb Silver or CarboFlex) twice weekly under the Unna boot. 1

Primary Recommendation: Odor-Absorbing Dressings

Since there is no infection present (no erythema, warmth, induration, pain/tenderness, or purulent drainage), antimicrobial therapy is not indicated. 2 The focus should be on odor absorption while maintaining the moist wound environment necessary for healing.

Cyclodextrin-Based Hydrocolloid Dressings

• Cyclodextrin-containing hydrocolloids demonstrate superior odor absorption compared to charcoal dressings in the presence of wound serum, which is particularly relevant given the copious serosanguineous drainage described. 1
• These dressings are self-adhesive, suitable for direct wound contact, and have significant fluid absorption capacity—addressing both the odor and drainage concerns simultaneously. 1
• They maintain effectiveness even when saturated with exudate, unlike charcoal which becomes deactivated by wound serum. 1

Charcoal-Based Dressings (Alternative)

• If cyclodextrin dressings are unavailable, charcoal-based products like Actisorb Silver, CarboFlex, or Carbonet can be used for odor control. 1
• Important caveat: Charcoal dressings lose effectiveness when saturated with wound serum, so they may be less ideal for wounds with copious drainage. 1
• These require adjunct fixation to hold them in place, which the Unna boot would provide. 1

Application Protocol

• Apply the odor-absorbing dressing directly to the wound bed before wrapping with the Unna boot. 3, 1
• Change twice weekly as requested, coordinating with Unna boot changes. 3
• Continue selecting dressings that control exudate and maintain a moist environment, as this is essential for venous ulcer healing. 2

What NOT to Use

Do not use topical metronidazole gel or other topical antibiotics in the absence of infection, as:

• They are indicated only for infected wounds. 1
• They can generate resistant organisms. 1
• Antimicrobial-containing dressings (silver, iodine) are not well-supported for routine wound management in non-infected ulcers. 2

Monitoring for Infection

While no infection is currently present, monitor at each dressing change for:

• Erythema, warmth, induration, or new pain/tenderness. 2
• Purulent secretions. 2
• Increased or worsening odor despite appropriate dressing use (may indicate developing infection). 1
• Systemic signs like fever are often absent in diabetic or ischemic patients, so rely on local signs. 2

Ensuring Continued Healing

• Compression therapy with the Unna boot remains the mainstay of treatment and should be continued as it is working to heal the wound. 2, 4
• The open-heeled Unna boot technique allows monitoring of the heel while maintaining compression. 3
• Debride necrotic tissue and callus as needed at dressing changes. 2
• Ensure the patient maintains elevation and appropriate activity levels to optimize venous return. 4