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Wounds: Leg ulcers

Key slides
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Wound care: leg ulcers
NHS CRD (1997) Effective Healthcare 3 (4), 1-12
SIGN 26 (1998) The Care of patients with Chronic Leg Ulcer
Clinical Knowledge Summaries_Venous Leg Ulcer_Feb 08
Wound care is a high cost area for patients and NHS in terms of
prescribing costs, patient QoL and NHS workforce time
The evidence base for therapeutics in much of this area is
limited
Value for money for the NHS is an important factor when
choosing treatments
Leg ulcers are a common, chronic, recurring condition
Prevalence of active leg ulcers is between 1.5 to 3 per 1000 and
increases with age. Its estimated that up to 20 per 1000
people over 80 yrs will suffer from a leg ulcer
Following healing, re-ulceration rates at one year range from
26% - 69%
Available treatments can reduce recurrence rates
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Leg ulcer aetiology
Clinical Knowledge Summary Venous Leg Ulcers_February 2008
Grey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50
Venous insufficiency 80 - 85%
Other causes:
Arterial disease
Mixed arterial and venous disease
Diabetes
Rheumatoid arthritis
Systemic vasculitis
Lymphoedema
Trauma
Others including malignancy
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Assessment of the patient - history
Clinical Knowledge Summary Venous Leg Ulcers_February 2008
Royal College of Nursing Clinical Practice Guidelines 2006
History suggesting venous
disease
History suggesting arterial
disease (c.10-20% patients)
Varicose veins, immobility, obesity Ankle Brachial Pressure Index less
than 0.8
Proven deep vein thrombosis in the
affected leg
Ischaemic heart disease, stroke or
transient ischaemic attack
Phlebitis in the affected leg Rheumatoid arthritis
Previous fracture, trauma, or
surgery
Diabetes mellitus
Family history of venous disease Peripheral arterial
disease/intermittent claudication
Symptoms of venous insufficiency:
leg pain, heavy legs, aching,
itching, swelling, skin breakdown,
pigmentation, and eczema
Smoking
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Assessment of the leg - examination
Clinical Knowledge Summary Venous Leg Ulcers_February 2008
CREST Guidelines for the Assessment and Management of Leg Ulcers 1998
Measurement of Ankle Brachial Pressure Index (ABPI) is the most
reliable way to detect arterial insufficiency
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Assessment of the ulcer
Clinical Knowledge Summary Venous Leg Ulcers_February 2008
CREST Guidelines for the Assessment and Management of Leg Ulcers 1998
RECORD RATIONALE
Size, depth, edges and site of ulcer Serial measures useful for progress
Ulcer base:
Epithelialisation/granulation/slough/
eschar/necrosis
Aid choice of dressing and indicate
progress of healing
Level of exudate:
Minimal/ moderate/ high
Will influence dressing choice and
frequency of dressing change
Signs of infection:
Enlarging ulcer, increased exudate,
pyrexia, foul odour, cellulitis
May indicate infection
Pain:
Assess level, frequency and duration
Treat to relieve distress and aid
compliance with treatment
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Referral to a specialist clinic before treatment
Clinical Knowledge Summary Venous Leg Ulcers_February 2008
Uncertain diagnosis
Suspected alternative causes of ulceration:
- Arterial or mixed venous/arterial ulcer. Refer people with
ABPI <0.8 for further assessment. If < 0.5 refer urgently.
Suspected malignant ulcer or rapidly deteriorating ulcer
Suspected rheumatoid ulcer, or ulcer associated with systemic
vasculitis
People with diabetes with an ulcer on the foot (according to local
arrangements)
Varicose veins or arterial insufficiency
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Lifestyle advice
Clinical Knowledge Summary Venous Leg Ulcers_February 2008
Self - care strategies include:
Keep mobile with regular walking if possible
Elevate legs when immobile
Use emollient and examine legs regularly for broken skin,
blisters, swelling or redness
Lose weight if appropriate
Stop smoking

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Venous leg Ulcer - treatment
Clinical Knowledge Summary Venous Leg Ulcers_February 2008

Irrigate the wound with warm tap water or saline, then dry. Strict
aseptic technique not required
Remove slough or necrotic tissue by gentle washing
If debridement is needed, it should be carried out by a trained
healthcare professional
Consider using potassium permanganate 0.01% soak if the
ulcer is malodorous
For uncomplicated, non-infected ulcers apply a low-adherent
dressing & replace weekly. (If heavy exudate - more frequent
change)
Other dressings may be used if needed - pain (hydrocolloid),
heavy exudate (alginate) or slough (hydrogel)
For uncomplicated, non infected ulcers and where indicated by
ABPI, apply compression bandaging - 4 or 3 layer if immobile,
or 2-layer if mobile
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Uncomplicated venous leg ulcer
Follow up during treatment
Clinical Knowledge Summary Venous Leg Ulcers_February 2008
Assess weekly for the first 2 weeks. If healing underway, assess
fortnightly or monthly, then 3 monthly
Change dressings at least once a week. Check for healing
and compliance with compression therapy and ask about
problems e.g. mobility, sleep, mood
If delayed or no healing, identify problems which may need
further treatment or referral
Check for complications
Check lifestyle advice is followed
If ulcer not healing or deteriorating at 12 weeks, look for signs of
arterial disease and repeat ABPI
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Venous leg ulcer - treating infection
Clinical Knowledge Summary Venous Leg Ulcers_February 2008
All chronic wounds are colonised with bacteria
Antibiotics should be used only if there is evidence of
cellulitis or active infection (e.g. pyrexia, increasing pain,
enlarging ulcer)
If there are clinical signs of infection present, clean ulcer with
warm tap water or saline before taking a swab
Start immediate empiric treatment with an anti-staphylococcal
antibiotic i.e. flucloxacillin or erythromycin 500mg qds for seven
days
Change dressing daily or alternate days to assess if infection is
improving
Do not use antimicrobial dressings
Do not start compression therapy if ulcer is infected
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Infected venous leg ulcer- follow up
during treatment
Clinical Knowledge Summary Venous Leg Ulcers_February 2008
SIGN 26 (1998) The Care of patients with Chronic Leg Ulcer
Reassessment and follow up frequency is different
for uncomplicated and infected ulcers
Review the patient within 3 days to assess response
to treatment, ideally followed by re-assessment every
two or three days until clinical improvement is seen
Reassess the ulcer as at initial assessment:
dimensions, site, base, odour and exudate
If infection is not responding, consider change of
antibiotic based on swab results
If signs of worsening infection, refer
After infection has settled, follow up as for
uncomplicated venous ulcers
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Venous leg ulcer - dressing choice
SIGN 26 (1998) The Care of patients with Chronic Leg Ulcer Clinical Knowledge
Summary Venous Leg Ulcers_February 2008

There is good evidence that the type of dressing used has
no effect on ulcer healing

Uncomplicated ulcer-use simple low-adherent dressing
Sloughy ulcer-hydrogel provides moisture that may help liquefy
slough
Moderate to heavily exuding ulcer-alginate or foam dressing
may help absorb exudate
Painful ulcer-occlusive hydrocolloid or foam dressing may
reduce pain

Simple non-adherent dressings are recommended in the
treatment of venous ulcers as no specific dressing has
been shown to improve healing rates
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Venous leg ulcer - compression bandaging
Clinical Knowledge Summary Venous Leg Ulcers

Below-knee graduated compression is the mainstay of
treatment to improve venous return, and to reduce venous
stasis and hypertension in uncomplicated venous leg
ulcers
Graduated compression delivers the highest pressure at the
ankle and gaiter area (40 mmHg), and pressure progressively
reduces towards the knee and thigh where less external
pressure is needed (18 mmHg)
High compression multilayer (four layer, three layer)
bandaging has improved healing rates over single layer
bandaging
An appropriately trained person should apply high
compression multi-layer bandaging, to avoid the risk of pressure
ulceration over bony points

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Venous leg ulcer - preventing recurrence
Clinical Knowledge Summary Venous Leg Ulcers_February 2008
CREST Guidelines for the Assessment and Management of Leg Ulcers 1998

Graduated compression stockings should be used for at
least 5 years after ulcer healing
Educate and explain to the patient the importance of preventing
recurrence through lifestyle changes and use of hosiery
Accurate measurement of limbs for compression hosiery is
essential
Follow up with 6-monthly Doppler ABPI checks
Class III (high) compression stockings are associated with less
recurrence than Class II (medium) compression stockings, but
may be less acceptable to the patient
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Arterial leg ulcers
Grey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50
Caused by reduced blood supply to the lower limbs either by a
block in the artery or narrowing of the arteries resulting in hypoxic
damage, ulcer formation and necrosis
Arterial ulcers account for 10% - 15% of leg ulcers
Typically occur over toes, heels and bony prominences of foot
Can take months or years to heal, are painful and often become
infected
Men over 45 years and women over 55 years are more likely to have
PVD, (peripheral vascular disease) and so are prone to arterial leg
ulcers
Modifiable risk factors: smoking, hyperlipidaemia, hypertension,
obesity, diabetes, decreased activity
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Arterial leg ulcers
Grey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50 Nelson EA et al.
Dressings and topical agents for arterial leg ulcers. Cochrane Database of
Systematic Reviews 2007, Issue 1.
Infection can cause rapid deterioration of an arterial
ulcer
It is not appropriate to debride arterial ulcers as this
may produce further ischaemia and formation of a
larger ulcer (specialist only)
Compression bandaging should not be applied
as severe damage to the leg can result
Choice of dressing is dictated by the nature of the
wound
Treatment options include reconstructive surgery or
angioplasty
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Summary: leg ulcer therapeutics
For both venous and arterial leg ulcers
Systematic assessment of the wound is essential for baseline data
and to evaluate healing and treatment efficacy
Regular wound reassessment is good clinical practice
There is insufficient evidence that one type of dressing is superior to
another in leg ulcer wound healing
Treat infection with systemic antibiotics not topical antimicrobials

Management of venous vs. arterial leg ulcers
Compression therapy is the mainstay of venous leg ulcer
management, but should not be used for arterial ulceration or infected
wounds
Increasing peripheral blood flow is the intervention most likely to
affect healing in arterial ulceration