Treatment of Venous Leg Ulcers

Venous leg ulcers (VLUs) are a very challenging condition for clinicians and wound care providers to treat. Venous ulceration is a common skin and lower extremity problem that affects roughly 1% of the population and approximately 3-8% of people 80 years or older.^1-4 The condition is a complication of chronic venous disease resulting from venous valvular incompetence and venous hypertension. Contributing factors for VLUs include inactivity, obesity, trauma/injury, diabetes, vasculitis, neoplasia, and older age.⁵ Outcomes for patients suffering from VLU are improved when the patient receives multidisciplinary care along with evidence-based wound care management.^6,7 VLUs are a very common condition treated in the wound care center as well as by health care providers and clinicians in podiatry, family practice, geriatrics, physical therapy, general surgery, and vascular surgery settings.

Clinical Presentation and Diagnosis

Venous ulcerations are typically located on the gaiter region of the lower leg, the area of the lower leg that is routinely covered by a sock. Common areas where VLUs are located include the medial aspect of the lower leg, medial ankle, and near the medial malleolus and can also be seen on the lateral lower leg and can also occur on the foot.⁸ On physical examination, venous ulcers are typically shallow and irregular in shape. Granulation tissue, fibrin, and exudate is commonly seen, as well as hemosiderin deposits, venous stasis dermatitis, and hyperpigmentation of the skin (Figure 1).

Appropriate diagnosis of a VLU is essential. Other types of ulcerations can occur on the lower extremity and/or foot, so understanding the clinical features of VLUs is an important step in their management. Common lower extremity and foot ulcerations include venous ulceration, arterial ulceration, pressure ulcerations, and neuropathic ulcerations
(Table 1).

Treatment

It is recommended that clinicians follow an evidence-based treatment approach for VLUs in which closure of the wound is the primary goal. The clinician should also formulate a treatment plan that prevents recurrence of the VLU once the wound is closed (e.g., compression hose and/or compression garments). The patient may require a vascular consult to treat the underlying condition.

Compression therapy is the standard of care for VLUs and it has been shown that venous ulcers heal more quickly when compression therapy is used.⁹ Compression therapy helps to reduce lower leg edema, addresses venous reflux, aids in wound healing, and helps reduce the pain associated with venous ulcers.¹⁰ There are many options available to the clinician when choosing compression therapy including one layer to various layers of compression.^11,12 Using a multi-layer compression system that can provide high compression (35-40 mmHg) for patients with an ankle brachial pressure index (ABPI) ≥ 0.8 (3M™ Coban™ 2 Two-Layer Compression System), and reduced compression (25-30 mmHg) for patients with an ABPI ≥ 0.5 (3M™ Coban™ 2 Lite Two-Layer Compression System) may provide clinical benefit. These multi-layer compression systems provide sustained pressure without slipping, reduces edema and leg pain, and supports healing.^13,14 This multi-layer compression system is also cost effective, providing sustained, therapeutic compression for up to 7-10 days.

Advanced wound care dressings (AWDs) are also part of the evidence-based treatment approach for VLUs. AWDs are often used under compression therapy to promote an environment conducive to wound healing. Using a collagen matrix with oxidized regenerated cellulose (ORC) and silver-ORC (3M™ Promogran Prisma™ Matrix) may help in this regard. In the presence of wound exudate, Promogran Prisma Matrix transforms into a conformable gel allowing contact with all areas of the VLU. The silver-ORC in the wound matrix serves as an antibacterial barrier and has been shown to reduce bacterial growth in vitro of common wound pathogens including Staphylococcus aureus, Pseudomonas aeruginosa, Eschericia coli, and Streptococcus pyogenes.¹⁵ The ORC component has been reported to lower the pH and reduce protease and matrix metalloproteinase levels which can be elevated in chronic wounds like VLUs.^16,17

Wound bed preparation helps with wound healing. Debridement of necrotic and non-viable tissue has been shown to reduce wound size in comparison to patients whose wounds were not treated with debridement.¹⁸ There are multiple options available for wound debridement including biologic, autolytic, enzymatic, mechanical, ultrasonic, and surgical debridement.

VLUs can produce high amounts of exudate. Managing exudate while also protecting the integrity of the surrounding skin is an important component of the treatment plan. Clinicians may consider a non-cytotoxic, hypoallergenic no sting barrier film (3M™ Cavilon™ No Sting Barrier Film) to protect the peri-wound. Additionally, selecting a primary dressing (such as 3M™ Tegaderm™ High Performance Foam Non-Adhesive Dressing or 3M^TM Tegaderm^TM Silicone Foam Non-Bordered Dressings) that can handle a high level of exudate and maintain an optimal wound environment can help minimize dressing changes, overall cost of care, and discomfort to the patient.

Case presentation

A 76-year-old female presented with a left leg wound (Figure 2) that had been present for more than 3 months and was unresponsive to treatment by her primary care provider. The patient’s previous care consisted of weekly applications of an Unna boot. Her past medical history was significant for coronary artery disease, hypertension, dyslipidemia, bronchiectasis, and chronic venous insufficiency. Examination of the left lower leg revealed dense hyperpigmentation from the midcalf down to her left foot. Reticular and spider veins were noted on her ankle and foot. 

A 4-mm punch biopsy was performed as the wound had been present for at least 3 months with no significant healing. The pathology report revealed benign skin with ulceration, suppurative inflammation and prominent stasis changes; no evidence of malignancy was noted. After the wound evaluation and the biopsy results, the wound was diagnosed as a VLU. 

At the patient’s next visit, wound debridement was performed (Figure 3), followed by application of  Tegaderm High Performance Foam Non-Adhesive Dressing as the primary dressing, and compression therapy with the Coban 2 Lite Compression System with dressing changes scheduled twice a week (Figure 4). Promogran Prisma Matrix was added to the patient’s treatment plan at week 3 (Figure 5). The patient’s wound improved considerably since her initial presentation, and at week 6 there was a notable decrease in the size and depth of the wound with robust granulation tissue present (Figures 6,7). At the wound care center, the goal is to achieve wound closure within 12 weeks of presentation. This patient is currently undergoing treatment and the wound is continuing to heal with decreasing wound size measured at each dressing change. Upon closure, a compression garment will be prescribed to help prevent reoccurrence and the development of new ulcerations.

CONCLUSION

This paper described an evidence-based approach for the treatment of venous leg ulceration. In patients with VLUs, a vascular consult to treat possible underlying conditions should be performed and may help prevent VLU reoccurrence. Additionally, wound debridement, advanced wound care dressings, and compression therapy use can help close these difficult wounds. Once closed, lifelong treatment with support hose and compression garments can help prevent recurrence.