Clinical Pathways for Management of Venous Leg Ulcers

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By the WoundSource Editors

Venous ulcers are known to be complex and costly. There is an array of evidence-based treatment options available to help formulate a comprehensive treatment plan toward wound closure. Health care professionals should utilize treatment options while encompassing a holistic approach to venous ulcer management. Involving the patient and/or caregiver in developing a treatment plan will increase the chances of successful wound healing outcomes. Wound closure is the primary goal of a treatment plan; however, preventing recurrence and infection should be considered just as important.

Evidence-Based Treatment Options

Compression Therapy
Compression therapy is considered the "gold standard" of care for prolonged treatment of venous ulcers. Compression therapy goals include edema management, venous reflux improvement, and enhanced healing.1,2 Compression therapy can consist of one layer to various layers.3

  • Elastic: bandages conforming to the size and shape of the leg.
  • Inelastic: zinc oxide–impregnated gauze wraps such as an Unna boot.
  • Dual compression: compression method combining elastic and inelastic bandages to be used simultaneously.
  • Stockings or custom garments: knee high, thigh high, toes in or out. Patient preference should be considered when selecting a garment; 30mmHg to 40mmHg strength is preferred.5,6
  • Pneumatic compression pumps: three types of pumps delivering variances of pressure gradient, inflation, and deflation cycles.4
  • Leg elevation: to increase deep venous flow and reduce venous pressure. Legs should be elevated above heart level.4

Advanced Wound Care Dressings
Dressing selection should be determined by wound location, size, depth, exudate amount, bioburden or biofilm, frequency of dressing change, payer source or cost, and availability.4 Many dressings are available with or without antimicrobial properties such as silver or honey. Use as clinically indicated.

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  • Absorbent dressings: alginates, foams, and super absorbents; charcoal available for odor control
  • Hydrocolloid: all shapes, sizes, and thicknesses; used as primary or secondary dressings
  • Impregnated gauzes (low-adherence or non-stick): oil emulsion, petrolatum gauze, and bismuth gauze
  • Collagen matrix: with or without silver

Antimicrobials and Antiseptics
Cadexomer iodine, povidone-iodine, medical-grade honey, peroxide-based preparation, and silver have shown evidence of improving wound healing of venous ulcers.7

Wound Cleansers and Surfactants
Wound cleansers, surfactants, and solutions are used to help remove exudate, contaminants, and foreign debris in wound bed preparation. There are rinse and no-rinse formulas.

Advanced Wound Care Therapies

  • Cellular and tissue-based products
  • Skin grafting: used as secondary therapy for ulcers when standard care fails

Medications

  • Pentoxifylline: hemorheologic agent affects microcirculation and oxygenation4
  • Aspirin (acetylsalicylic acid [ASA]): inconsistent evidence concerning benefits and harms of oral ASA in treatment of venous ulcers4
  • Statins: vasoactive and anti-inflammatory effects4
  • Phlebotomics: improved venous tone and decreasing capillary permeability4
  • Antibiotics: warranted only if infection is suspected4

Debridement Methods
Wound bed preparation has been shown to help expedite healing rates. Using the five methods of debridement will help move venous ulcers toward wound healing. Patients treated with sharp debridement at each physician’s office visit had significant reductions in wound size compared with those patients not treated with debridement.8

  • Biological: maggot therapy
  • Enzymatic: collagenase ointment
  • Autolytic: moisture-retentive dressings such as hydrocolloid, transparent, and alginate dressings
  • Mechanical: wet-to-dry dressings, whirlpool, pulse lavage
  • Surgical; sharp debridement (can be performed in the operating room, in the clinic, or at the bedside)

Endovenous Intervention
Endovenous interventions include endovenous ablation, ligation, subfascial endoscopic perforator surgery, and sclerotherapy. Recent trials show faster healing rates of venous ulcers when early endovenous ablation to correct superficial venous reflux is performed in conjunction with compression therapy, compared with compression alone or with delayed intervention of an ulcer that has not reached wound closure after six months.9

Multidisciplinary Team Approach
The complexity of venous ulcer management and treatment warrants a team effort. It takes a multidisciplinary team approach to focus on various comorbidities and issues a patient may have. Utilizing a specialized team member will provide a comprehensive plan of care. Communication with each team member while focusing on a patient-centered approach is critical to preventing gaps in care. Working together, the team can move toward successful outcomes for their patients.

References
1. O'Donnell TF Jr., Passman MA, Marston WA, et al.; Society for Vascular Surgery; American Venous Forum. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg. 2014;60(2)(suppl):3S-59S.
2. Mauck KF, Asi N, Elraiyah TA, et al. Comparative systematic review and meta-analysis of compression modalities for the promotion of venous ulcer healing and reducing ulcer recurrence. J Vasc Surg. 2014;60(2)(suppl):71S-90S,e1-e2.
3. Hettrick H. The science of compression therapy for chronic venous insufficiency edema. J Am Col Certif Wound Spec. 2009;1(1):20-24.
4. Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Repair Regen. 2009;17(3):306-311.
5. Vandongen YK, Stacey MC. Graduated compression elastic stockings reduce lipodermatosclerosis and ulcer recurrence. Phlebology. 2000;15(1):33-37.
6. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2014;(9):CD002303.
7. O'Meara S, Al-Kurdi D, Ologun Y, et al. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 2014;(1):CD003557.
8. Bonkemeyer Millan S, Gan R, Townsend PE. Venous ulcers: diagnosis and treatment. Am Fam Physician. 2019;100(5):298-305.
9. Gohel MS, Heatley F, Liu X, et al.; EVRA Trial Investigators. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018;378(22):2105-2114.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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