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Information

Editors

KenMalanin
HannuKuokkanen

Treatment of Lower Extremity Ulcers

Essentials

  • 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 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 )
    • 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.

Reducing leg oedema of venous origin Compression Therapy for Treating Post-Thrombotic Syndrome, Intermittent Pneumatic Compression for Treating Venous Leg Ulcers

  • Elevation of leg
  • Supportive bandages and compression stockings
    • To be noticed
      • 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.
    • Supportive bandages Compression for Venous Leg Ulcers
      • 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
  • After the ulcer has healed, compression stockings should be used permanently if the underlying venous disease cannot be surgically corrected Compression for Preventing Recurrence of Venous Ulcers.
  • Preventing oedema is beneficial also in other than venous type of lower extremity ulcers.

General management Oral Zinc for Chronic Leg Ulcers

  • Assessment of nutritional status (e.g., blood haemoglobin and plasma albumin concentrations)
  • Correction of anaemia
  • Proper treatment of diabetes
  • Proper treatment of cardiac insufficiency
  • Improvement of peripheral circulation. Pentoxifylline combined with compression is beneficial Oral Pentoxifylline for Treatment of Venous Leg Ulcers.
  • Possible smoking should be stopped.
  • Take a bacterial culture if the ulcer shows clinical signs of infection and initiate internal antimicrobial treatment Erysipelas.

Topical treatment Negative Pressure Wound Therapy for Treating Leg Ulcers, Dressings and Topical Agents for Arterial Leg Ulcers, Topical Silver for Treating Infected Wounds, Foam Dressings for Venous Leg Ulcers, Alginate Dressings for Venous Leg Ulcers, Antibiotics and Antiseptics for Venous Leg Ulcers, Skin Grafting for Venous Leg Ulcers, Negative Pressure Wound Therapy for Treating Foot Wounds in People with Diabetes Mellitus, Electromagnetic Therapy for Treating Venous Leg Ulcers, Therapeutic Ultrasound for Venous Leg Ulcers

  • 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 cream administered 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.
    • Sodium hypochlorite solution 0.3%
    • Aluminium subacetate 0.5%
    • Silver nitrate solution 0.1-0.01%
    • Povidone-iodine (local antiseptic)
  • Topical enzyme therapy (e.g. clostridiopeptidase ointment)
  • Propylene glycol gel
  • Alginate hydrogel
  • Hypertonic saline gel

Ulcers covered with dry yellow and brown coating

  • Bathing or compresses to soften slough (see above)
  • Mechanical cleansing
  • Hydrocolloid paste + sheet
  • Wound gels
  • Topical enzyme therapy
  • Larva therapy
  • CO2 laser vaporization

Secretory necrotic ulcer

  • Bathing/showering (see above)
  • Mechanical debridement
  • Topical enzyme therapy (see above)
  • Hydrofiber dressing
  • Alginate dressing
  • Absorbent polyurethane membrane

Infected and suppurative ulcers

  • Antiseptic baths
    • Potassium permanganate (see above)
  • Mechanical cleansing
  • Moist dressings: silver nitrate solution of 0.01 to 0.1%, zinc sulphate solution of 0.25%
  • Cadexomer iodine powder, -ointment, -ointment dressing (moisturising of the wound reduces smarting sensations)
  • Activated charcoal dressings reduce foul smell from the wound.
  • Hydrofiber and alginate dressings with or without silver supplement

Clean and granulating wound

  • Light showering
  • Hydrocolloid wound sheets (see above)
  • Polyurethane foam pads
  • Ointment stocking
  • Negative pressure wound therapy
  • Skin grafting

To be remembered in local treatment

  • The treatment agents often cause allergic contact dermatitis (presenting as eczema around the wound).
  • Before mechanical cleansing, a painful ulcer is anaesthetized using lidocaine gel or lidocain-prilocain cream Topical Agents or Dressings for Pain in Venous Leg Ulcers. Internal analgesic may be used if necessary.
  • 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.

Surgical treatment Endovenous Ablation for Venous Leg Ulcers

  • 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.