Type of ulcer
Location
Basic pathology
Pain
Number
Ulcer features
Associated findings
Diagnosis
Venous ulcer
Gaiter area
Venous hypertension
Not prominent
Usually single/multiple can occur
Sloping edge; floor pink granuln
Varicose veins; eczema and LDS
Duplex scan
Arterial ulcer
Forefoot
Ischemia
++++
Single/multiple
Pale floor
Cold extremity; absent pedal pulses
ABPI less than 1; duplex scan
Diabetic ulcer
Sole of foot; heel
Multifactorial; neuropathy
+/−
Single/multiple
Extensive sloughing and local tissue damage
Sensory, motor, and autonomic neuropathy
Hyperglycemia and local features with slough and tissue loss
Rheumatoid ulcer
Leg
Autoimmune
+++
Multiple
Ulcerated nodule
Poly arthritis
Rheumatoid factor; ESR elevated
Vasculitic ulcer
Leg
Multifactorial/autoimmune
+++
Multiple
Shallow multiple, surrounding skin black
Systemic features fever, joint pains, and stomach upset
ANA; extractable nuclear antigen (ENA) and ANCA
The workup would include all the relevant investigations to rule out these conditions. A duplex scan is the gold standard for the confirmation of vascular (arterial or venous) origin. Combined with ankle brachial pressure index, this will help in differentiating arterial and venous pathology. Blood sugar estimation, rheumatoid factor, ANA and ANCA, and biopsy of ulcer edge would help to rule out other common pathologies.
Once the venous origin of the ulcer is confirmed, a well-defined strategy is essential in the overall care of the patient. Ideally, the management should be undertaken in dedicated centers where the personnel are trained for such care. This is more so when CT is combined with ulcer care [3, 4].
The size of the ulcer should be documented on first encounter and subsequently every month. A simple method is by serial digital photography. Smearing the edge of the ulcer with povidone-iodine solution and taking an imprint on a clean graph paper can be a precise method of assessing the surface area of the ulcer.
Sequential Steps of Ulcer Care
The following steps are important in the care of the ulcer. The dressing techniques should be clean and is aimed at preventing cross infection. Strict asepsis is not necessary [3].
1.
Cleaning the ulcer should be kept as simple as possible. The ulcer can be washed with tap water. No advantage was observed by using sterile saline [4]. The surrounding skin can be washed with a mild soap.
2.
Debridement can be carried out, if necessary by sharp excision, to reduce the necrotic tissues. But trials have not demonstrated faster healing following debridement [3]. No special advantage was observed with other methods of debridement such as chemical or autolytic agents [3]. Hydrogel and an enzymatic dressing are alternatives to surgical debridement [4].
3.
Biopsy of the ulcer edge is recommended when there are atypical features such as rolled or raised edge [3].
4.
Topical application aimed at controlling infection and promoting wound healing is a debatable issue. Bacterial swabbing and culture is not routinely needed unless there are evidences of clinical infection [3]. Topical antibiotic applications are best avoided because they can sensitize the skin; same thing holds for topical agents containing lanolin [3]. Topical antimicrobials such as silver-based wound dressings are recommended by some workers [4]. There are conflicting reports regarding the efficacy of topical application of growth factors [3]. Systemic antibiotics should be limited to the treatment of obvious infections of the ulcer or surrounding skin such as presence of systemic signs, peri-wound cellulitis, foul odor, or gross purulent discharge [4].
5.
Ulcer dressings. Generally wound dressings are of three categories: passive (nonocclusive), interactive (semiocclusive and occlusive types), and active (biological types) [4]. The passive dressings (nonocclusive dressings) protect the wound from trauma and potential infection. An example of nonocclusive dressing is dry gauze with pad and bandage. The interactive types of dressings maintain a moist warm wound environment and help to control the amount and composition of wound exudate. They also reduce heat loss and water evaporation. They may be semiocclusive or occlusive type. The common types of semi occlusive/occlusive dressings include hydrocolloids, hydrogels, films, foam, and alginates. The active or biologic dressings may be living human dermal equivalent (LHDE), platelet products – autologous or recombinant and growth factors (epidermal growth factor; GMCSF, etc.).
There is no ideal dressing material for venous ulcers. The saline wet–to–dry gauze dressing is a simple and popular form of dressing. It functions as a semiocclusive dressing as long as it is wet, but when it becomes dry, it changes over to nonocclusive type [4]. No extra benefits were observed between the occlusive and semiocclusive dressings [3]. The use of human skin equivalents or the growth factors has not reported to confer any extra benefit [3].
The frequency of dressing changes would depend on whether CT is combined or not and the amount of exudate. Along with CT, the frequency would be once or twice weekly. More frequent change of dressings would be needed if the exudate is heavy. If not combined with CT, dressings could be changed daily or on alternate days.
6.
Management of pain. Venous ulcers are generally considered to be painless unless complicated by infection. In the event of severe pain, it is important to rule out other causes of ulceration especially ischemia. Fifty percent of pure venous ulcers can be painful [3]. In such situations, an opioid analgesic would be useful. Promoting healing by CT can reduce pain considerably. Pain can be precipitated during dressings, debridement, and other interventions. The use of Eutectic Mixture of Local Anesthetic (EMLA) as a cream is recommended in such situations [4].
7.
Skin grafting for venous ulcers.
Split-thickness skin grafting should be considered for large ulcers requiring extended time to heal. Pinch graft is considered better since it can be carried out as a day case without hospitalization [4].
Along with the local treatment measures, it is important to provide optimal general nutritional support for these patients.
Compression Therapy for Venous Ulcers
Definition and General Considerations
Compression therapy (CT) is defined as the direct application of external pressure to the limb with the idea of improving the signs and symptoms of chronic venous insufficiency. This is the primary modality of treatment in patients with venous ulcers. It is an ambulatory form of therapy and has replaced the time-honored method of treating venous ulcers by absolute bed rest and limb elevation. CT is practiced in combination with other interventions, and not in isolation. Such a combined approach would improve the outcome and minimize ulcer recurrence [5]. The time taken for ulcers to heal with CT is approximately 3 months [6]. Noncompliance is the stumbling block in the effective execution of CT.
In simple terms, CT works by squeezing the limb, thereby reducing the edema and aiding venous return toward the heart. The main effect of compression is to lower the venous pressure. The optimum external pressure required to achieve therapeutic effect is debated. It has been demonstrated that in the erect position, an external pressure of 35–40 mm of Hg can narrow the leg veins. When the pressure exceeds 60 mm the veins are occluded [6]. From this, it has been deducted that the effective external pressure for compression would be 35–40 mm of Hg. A safe upper limit of sustained pressure would be 60 mm of Hg [6]. Compression therapy provides several beneficial effects on the venous system, microcirculation, and the lymphatic system [7, 8].
1.
It improves venous pump function.
2.
It improves microcirculatory hemodynamics favoring resolution of edema.
3.
The levels of inflammatory mediators such as vascular endothelial growth factor and tumour necrosis factor alpha, responsible for tissue damage in CVI, are lowered by compression.
Not all patients with CVI respond to compression therapy. The nonresponders include elderly and obese patients, patients with combined venous and arterial ulcers, and those with large ulcers and with multiple recurrences [6].
Methods of Providing Compression Therapy
There are several methods for providing CT. The common methods used in clinical practice include the following [6]:
1.
Compressive bandages – multilayer bandaging
2.
Compression stockings
3.
Intermittent pneumatic compression (IPC)
4.
Unna’s paste boots and velcro – band devices (legging orthosis)
The most popular and probably the most effective method among these would be CT by multilayer bandaging. This technique will be described in detail.
Compression Therapy by Multilayer Bandaging
Multilayer bandaging is the most widely practiced technique of CT. For a proper understanding of compression therapy, the clinician should be familiar with the various types of bandages and their properties.
The Properties of Bandages [5]
There are several properties for a bandage. A working knowledge of these is necessary in choosing the appropriate materials for providing CT. Tension is the amount of force applied to the bandage during application. This is supported by the elastomeric properties of the materials used. Extensibility is the ability to increase in length (stretch) in response to an applied force. Power is the amount of force required to cause a specific increase in length. Elasticity is the ability to return to original unstretched length when the tension is reduced. Stiffness of bandage is defined as the increase in pressure applied per centimeter increase in leg circumference [6].
Classification of Bandages
The simplest method of classification is based on the degree of in vitro extensibility of the bandage [6]. This decides their ability to maintain a predetermined level of compression. Based on this property, two types of bandages are recognized: inelastic bandages and elastic bandages.
The inelastic bandages are of two types:
1.
The rigid bandage. Type I bandage; retention/conforming bandage – extensibility 0–10 %
2.
The short stretch bandage. Type II bandage/supporting bandage – extensibility is 10–100 %
The elastic bandages. Type III; long stretch/compression bandage – extensibility over 100 %
Another system of classification is also popular [8]. The details are provided in the following table (Table 15.2).
Table 15.2
Classification of bandages
Type of bandage | Use |
|---|---|
Type I | Retention/conforming bandage |
Type II | Light support bandage |
Type III | Compression bandage |
III A | Light − 14 to 17 mmHg |
III B | Moderate – 20 to 40 mmHg |
III C | High – 40 to 60 mmHg |
III D | Extra high – over 60 mmHg |
Dynamics of Compression Therapy
1.
Sub–bandage Pressure. This is defined as the amount of pressure exerted by the bandage on the tissues. This is calculated by the Laplace’s Law: Pressure = N × T × 4,620/C × W
N = number of layers applied; the more the layers, the greater the pressure.
T = bandage tension; the greater the force, the greater the tension.
C = limb circumference; the smaller the circumference, the greater the pressure.
W = width of bandage; the narrower the bandage, the greater the pressure.
2.
Resting Pressure. This is the sub-bandage pressure with the patient in the supine position.
3.
Working Pressure. This is the higher peaks of pressure developing during exercise, such as walking, with the bandages on.
4.
Static Stiffness Index (SSI). This is the difference between supine and standing pressures measured at B 1 point (medial aspect of leg where gastrocnemius tendon turns into muscular part) [9, 10]. A higher stiffness indicates relative inelasticity of the bandage. (The long stretch bandage has an SSI less than 10 mm while the short stretch has a value more than 10 mm. It is now known that the SSI is maintained when multiple layers of elastic bandage are applied over each other.)
The Long Stretch (Type III/Elastic Bandage)
This can exert a high resting pressure. But it changes shape with the limb when edema resolves or when the muscles contract from within. Hence, the working pressure does not peak much [8]. The high resting pressure is sustained till 1 week. Long stretch bandages are easy to apply but the high resting pressure induces a feeling of tightness [6].
The Short Stretch (Inelastic/Type II Bandages)
Their stretch is caused by the weave of the bandage. Since type II bandage cannot change shape with the limb, the sub-bandage resting pressure is low in the supine position. When the patient walks, the increased pressure exerted by the muscles from within is resisted by the stiff bandage. This results in high working pressure. This increased pressure is redirected back to the deep veins, squeezing them better and improving the venous drainage [8]. When edema subsides, the bandage cannot conform to the smaller limb size and so it becomes loose. Frequent reapplications may be needed till the edema has resolved. It is useful for patients who have bandage-related pain at night because it cannot exert a high resting pressure [8]. Calf muscle pump function can be improved with this bandage because it exerts a higher working pressure. Overcompression is rare. Loss of bandage pressure after application and the cumbersome application techniques are drawbacks [6].
It is not recommended to apply high compression with a single elastic compression bandage since it can produce considerable pressure damage [6]. Several layers of elastic bandages applied over one another will reduce the elastic property and make it increasingly inelastic [8]. The same is true when two stockings are applied over each other or if several components of different materials are used. This effect results from increased friction between the different layers, which opposes the expansion of the limb [6].
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