The aetiology of an ulcer must be identified and the treatment planned according to it.
If you cannot identify a clear aetiology for the ulcer, take a biopsy from its edge.
Successful treatment often requires multidisciplinary approach.
The only effective treatment of wounds caused by arterial circulatory insufficiency is circulatory repair Lower Limb Ischaemia.
In wounds of venous origin, the essential measures include control of oedema and possible surgical interventions directed at venous circulation Venous Insufficiency of the Lower Limbs.
In wounds associated with systemic diseases, the treatment is directed at the primary disease.
The aim of topical treatment is to create a favourable environment for healing, to clean the wound and to protect it from contamination.
Start effective treatment as soon as the wound appears because a delay decreases the probability of healing.
Keep the treatment economical and simple and target the underlying primary cause of the ulcer.
Ulcers that do not respond to conservative treatment require surgical therapy.
Differential diagnosis
About 90% of lower extremity ulcers are caused by vascular diseases.
Venous ulcer (the most common type; pictures 1234)
Venous and arterial ulcer
Arterial ulcer
Hypertensive ulcer
Calciphylaxis ulcer
Diabetic ulcer
Livedoid vasculopathy
Vasculitic ulcer
Pyoderma gangrenosum ulcer
In addition, many rarer causes, e.g., tumours may lead to ulceration of the skin.
Evaluate the arterial blood circulation. If the peripheral pulses in the lower extremities cannot be reliably felt, record the ankle-brachial systolic blood pressure index (ABI) with a pen Doppler device (video Measurement of Ankle Pressure and Abi) . ABI is normally 1 or more. ABI ≤ 0.9 indicates impaired arterial circulation in the lower extremity Doppler Stethoscopy in Diagnostics.
Because of media sclerosis in the arteries of the lower extremities, patients with diabetes may have misleadingly high ABI values. In such cases, the toe-brachial index (TBI) performed in a vascular investigation unit may reflect the state of the arterial blood circulation more reliably.
Sufficient arterial circulation in the lower leg must be ensured before prescribing supportive bandages or compression stockings by feeling for the pulse of the arteries of the metatarsus and ankle. If these cannot be felt, ABI should be determined and it must be at least 0.8.
Contraindications to supportive bandages and compression stockings are untreated cardiac failure and severe arterial insufficiency in the lower leg (ABI < 0.5). These conditions must be corrected before oedema can be efficiently treated.
If the patient has impaired cutaneous sensation due to, for example, diabetic nephropathy, the lower extremity must be carefully monitored to prevent pressure injuries.
Short-stretch elastic bandages can be worn 24 hours a day. They are only removed for wound care.
Multi-layer bandaging
Adjustable compression textile ("legging") in problematic cases
Compression stockings
Compression class of the stockings varies between 1 and 3. The compression class is correct when the stocking keeps the oedema at the minimum, the patient is able to pull it easily on by using an aid, and the stocking feels comfortable on.
In practice, compression class 2 is most often used in primary care. A pressure gauge positioned under the stocking can be used to ensure that the compression stocking provides the correct pressure profile.
Intermittent pneumatic compression treatment Leg Oedema
There are hundreds of topical ulcer treatment products available on the market: choose a few that are suitable for the different stages of ulcer treatment and learn how to use them.
The aim is to remove any dead tissue and purulent exudate to create optimal healing conditions for the ulcer.
Lidocaine gel or lidocaine-prilocaine creamadministered on the ulcer and covered with a plastic wrap for a period of 30-60 minutes before the procedure help in relieving the pain associated with wound cleansing.
Comparative knowledge about the different alternatives for topical treatment is scarce.
Ulcers with black necrosis
The cheapest and fastest method for removing the black coating is to use tissue forceps, scissors and/or a knive/curette.
Additionally, bathing or compresses to soften the necrosis may be used
Potassium permanganate solution (KMnO4, 0.5 g per 5 litres of water)
Dissolve one 400 mg tablet of Permitabs® (or equivalent) in 4 litres of water and soak the ulcer once daily. The solution will stain the container, towel and nails dark brown.
Extend the time between dressing changes when the wound is cleansed and the secretion has decreased.
Avoid drying of the wound when changing the dressings.
Remember oedema prevention.
Referral to specialized care
As an emergency: acute wound infection causing systemic symptoms
As an emergency or urgently: the patient develops ischaemic pain
Elective referral: the ulcer will not reduce in size within a few weeks with adequate treatment or the reduction ceases. Surgical treatment is also indicated if a bone, joint or tendon is visible.
Consult a specialist if you are uncertain about the cause of the wound.
The surgery for a leg ulcer is a simple plastic surgery procedure that consists of an excision of the ulcer after which the remaining healthy tissue is covered by a free skin graft. 80% of leg ulcers improve after surgery.
A leg ulcer must always be treated surgically if
it was caused by trauma
malignancy is suspected.
If the patient has a venous leg ulcer and there is no decrease in the wound size after treatment of 1-2 months duration, a plastic surgeon should be consulted at the latest. A vascular surgeon is consulted after the plastic surgery consultation if necessary.
After surgery, the patient must wear a supportive bandage and keep the skin graft area clean.
Arteriosclerotic and diabetic lower extremity ulcers should be treated by a team of specialists including at least a vascular surgeon, a plastic surgeon, a specialist in internal medicine and a dermatologist.
Pinch skin grafting may be carried out by dermatologists or general practitioners. Plastic surgeons do not recommend pinch grafting for large (more than 3 cm) ulcers.
Continued treatment and monitoring after skin grafting are of utmost importance.
If the leg swelling cannot be controlled with compressive bandaging or stockings the wound will easily recur.