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Approaches to successful leg ulcer management

Rachael Smithdale
RGN Dip Healthcare Practice

Leg Ulcer Specialist Nurse
NHS Wandsworth

There is rarely anything straightforward about managing a leg ulcer, which is essentially a symptom of other underlying problems. Addressing a few critical factors from the start can help prevent long periods of delayed healing. This article will demonstrate how successful leg ulcer management can be achieved

It is very easy to want to “jump right in” with treatment when first meeting a patient with a leg ulcer; after all, when most practitioners see a wound they want to dress it. While in the short term it's a reasonable measure, in the long term it is not the solution. Addressing a few important elements at the beginning, such as holistic assessment, compression therapy (based on outcome of assessment), patient involvement and involvement of the multidisciplinary team make all the difference in realising a more successful approach to leg ulcer management.

Holistic assessment
Sometimes it feels overwhelming to think about doing an intensive assessment of a patient and their wound. Often it is time-consuming enough just to do a simple assessment of the wound itself, looking for signs of infection, the type of tissue and exudate levels, and then trying to work out which dressing (of the hundreds available) is best for your patient.

However, the “let's just get started and see” approach, just putting a dressing on, or giving a course of antibiotic therapy, is unlikely to achieve healing in a reasonable period. Time has a habit of marching on and before you realise it weeks and months can drift by with no discernible improvement, thereby costing far more (nursing time is one of the most costly elements of wound care).1 Meanwhile, both parties get anxious and frustrated, and eventually taking action and completing an assessment, or at least getting specialist advice, achieves healing within a month or two. It shouldn't have to be like this.

It is recognised that an holistic assessment really is the most critical factor in successful leg ulcer management.2,3 In terms of how quickly this should be undertaken it is worth acknowledging that the older or larger an ulcer is, the more difficult it is to heal.4

Leg ulcer assessment is a complex process and any registered healthcare practitioner undertaking this should be properly trained. While many nurses are moving into the area of diagnostics and prescribing, leg ulcer management has remained in the hands of nurses for some time. Generally, patients are referred to nursing services with a “leg ulcer”, but as a diagnosis this is not really meaningful; unfortunately, even now a specific diagnosis is not routinely made and care is often commenced without a great deal of assessment.5

There are many potential causes of leg ulcers (see Box 1), but chronic venous hypertension (CVH) and peripheral arterial occlusive disease (PAOD), or a combination of the two, are the most common. Many patients have leg ulcers with multiple causative diseases or factors that can delay healing.6
Therefore, a differential diagnosis must be undertaken. The use of a structured leg ulcer assessment tool that incorporates particular elements (shown in Box 2) ensures best practice.2,3
Only when a detailed assessment is complete can a conclusion be drawn about the most likely cause, and only then is it possible to make a plan and commence treatment.

[[Leg ulcers Box 1]]
[[Leg ulcers Box 2]]

Compression therapy
Strong graduated multi-component compression bandage systems are considered to be firstline treatment for patients with uncomplicated venous leg ulcers.2,7 For those patients who do not have numerous other medical problems; who can cope with the treatment; are able to find a good balance between keeping mobile and elevating their legs; and who are cared for by practitioners skilled and experienced at applying compression therapy, the potential for healing within 12-24 weeks (if not earlier) is quite good.

However, the reality in practice can sometimes be quite different. Many patients often have more than one complicating medical factor, which may make strong (>40-60 mmhg) levels of compression unsafe (eg, significant PAOD, unmanaged cardiac failure), or inappropriate if venous disease is not a factor. The therapy itself can be quite difficult to adjust to, particularly for patients having problems with pain, as initially the bandaging may be very difficult to tolerate, not to mention the numerous social problems attached to compression bandaging (for example, footwear, mobility and bathing).

Practitioner knowledge about application or the underlying principles of compression therapy, such as how the therapy aids healing and how therapeutic levels of pressure can be achieved, are vital in terms of helping patients to persevere with this treatment. Only with knowledge and insight can workable, practical solutions be achieved; without this it is understandable that patients will reject the treatment.

Many factors need to be considered when assessing a client for, and deciding on, the most appropriate type or level of compression (see Table 1). It is possible to apply various levels of compression from mild to very strong (see Box 3), using different types of bandage systems such as elastic or inelastic, cohesive or non-cohesive, using different application techniques, hosiery and flowtron or a combination of these.8

[[Leg ulcers Tab 1]]

[[Leg ulcers Box 3]]

Whatever is decided as a starting point for treatment, it's important to have a revision date in mind. Of course, a review of the treatment can be carried out at each dressing change, and while in some circumstances it may be obvious that a treatment is not appropriate, it is not good practice to constantly change treatments. Four weeks is a realistic review point. If the treatment is appropriate then this should be visible by means of reduction in wound size or at least other factors such as reduction in devitalised tissue (slough or necrosis), or exudate levels. If there has been no improvement then the patient needs to be reassessed, and ideally referred for specialist assessment.9

Patient involvement
Working in partnership with our patients is critical to the success of any intervention. After all, it is their leg, their ulcer and their likely long-term condition. Remember, the ulcer is essentially a symptom of another underlying problem; and hopefully the patient won't have to contend with living with a wound indefinitely, although some will; and even those patients who do heal are likely to have to make long-term lifestyle changes to prevent recurrence.

Many patients are well informed when it comes to the management of their condition, so the starting point is always to get an insight into the patient's own health beliefs and knowledge of their condition. Some balance is required here as some patients may misinterpret this kind of approach as a practitioner not knowing what they are doing.  

As already mentioned, compression therapy and other healthcare advice can be difficult treatments to contend with and adapt into day-to-day life. Patients are frequently labelled as being non-compliant when they refuse or show some reluctance to this therapy or our advice. How often do we really put ourselves in our patient's shoes? We automatically assume that healing the leg ulcer is the patient's most important goal (because that's our goal), but for some people the goal may be getting rid of the pain so they can get a good night's sleep or finding a way to treat the wound that still enables them to work as they have a mortgage and bills to pay. We will only know these things by getting to know our patient. Patient concordance with treatment boils down to a few key elements (see Box 4), putting them in to practice can lead to satisfying results for both the patient and the practitioner.10

[[Leg ulcers Box 4]] 

Involvement of the multidisciplinary team
While leg ulcer management is firmly in the hands of primary care nurses, other members of the primary care team or secondary services have a role to play. The complexity of these wounds and their long-term nature often require referral on to another service at some point, either for diagnosis, treatment or prevention of recurrence.2,3 It is also worth exploring the range of services available that can help manage wider contributory factors, such as mobility, that may be resolved or improved by the involvement of physiotherapists, chiropodists, orthotics, specialist footwear, or occupational therapists.10 

The majority of uncomplicated venous ulcers can ideally be identified and managed entirely in primary care, however there is sufficient evidence to suggest that in regards to superficial venous disease further assessment and surgical intervention can play a significant role in preventing recurrence.11 In light of the risk of recurrence it is important to start discussing this option during the treatment phase so the patient has the opportunity to make an informed decision about referral onto a vascular team.

For patients with significant PAOD, referral on to a vascular surgeon will be imperative and its urgency should be guided by presenting signs and symptoms such as a rapidly deteriorating ulcer, intermittent claudication, night or rest pain.

Where the ulcer diagnosis is uncertain or when treatment with compression is not showing signs of healing, or is actually resulting in deterioration, patients should be referred to a wound care specialist nurse/team or dermatologist (depending upon service provision in the region). Obviously further assessment is required and this may involve blood tests, wound biopsy, radiological exam and further medical assessment and management. Once again, having a set date for review of treatment and planned reassessment can ensure timely referral on.2,3

Case study
Ray is a 72-year-old man who lives at home with his wife. He had a small ulcer on his left medial malleolous that had been present for four months. He explained that it had started after a worsening of his eczema and he had been trying to manage it himself with simple adhesive dressings and his compression sock.

On further investigation it became apparent that his “compression sock” is a very old TED stocking. Ray has a previous history of venous ulcers - the last one was over five years ago, which he was able to manage himself with over-the-counter remedies, although it did take a few months to get better. He has had previous surgery for varicose veins (over 30 years ago) and there are numerous visible venous skin changes, such as ankle flare, haemosiderin staining, varicose veins and varicose eczema. His mother had terrible problems with her legs - he could always remember her legs being bandaged. Ray has also had bilateral knee replacements and a left hip replacement (all within the last 10 years). His mobility is quite good and he is able to walk without the use of any aids, although he does not actively take regular exercise. Apart from taking a statin for raised cholesterol levels there are no other significant health factors.

Ray's ulcer is located in the retromalleolar area; it is relatively small and only produces a little serous exudate. He reports an occasional stinging sensation from the wound and only very occasionally feels the need to take pain relief; the itching sensation from the area is more of a problem to him. He has no foot or limb shape problems and his ankle circumference is 24 cm. He is willing to consider any treatment and is keen to heal the wound as quickly as possible as he is planning a holiday in a few months' time.

Ray was keen not to attend the surgery too often for treatment, and as the wound and surrounding skin didn't require frequent attention, weekly application of a multi-component elastic compression system (18-25 cm kit) was commenced. This system provides a moderate-strong level of compression. The bandaging, along with a good emollient and a simple non-adherent dressing, plus a shaped pad (several layers of gauze, cut into the shape of an ear to sit around the malleoli applying some direct pressure to the wound bed), were used for a month. During this time, Ray was also encouraged to take a daily walk and elevate his legs to heart level when resting. While the surrounding skin showed some signs of improvement the ulcer was not reducing in size.

Ray was coping very well with the compression and actually felt the benefit it offered in supporting his leg. The itching was only really an issue when the bandage was removed. An agreement was made so that Ray could remove his bandaging to shower as usual before his appointments. In light of the slow progress and the severity of Ray's venous disease, and taking into account that his ankle circumference was on the upper limits of the bandage kit he was presently using, his compression was increased by changing bandage components (25-30 cm kit), no other changes were made to the skin or wound treatment and this time healing was complete within six weeks.

The compression bandaging was continued for four weeks post healing in order to control any residual oedema and allow further maturation of wound before transferring to class 3 compression hosiery. During this period referral for further venous assessment and corrective surgery were discussed, and while Ray agreed to referral to the vascular team for further assessment he declined further surgical intervention preferring to manage with conservative treatment.

In comparison, perhaps, with many patients with leg ulcers, Ray's ulceration was technically uncomplicated. The major cause of his ulcer was CVH with no other significant factors; he was motivated in wanting to heal his wound and willing to consider all options. He was able to tolerate strong levels of compression, he had support from his wife and he was able to envisage and consider the chronicity of his disease and the need to look at long-term management options.

Of course, not all patients will be in the same situation, but by implementing the four key elements of successful leg ulcer management discussed in this article positive outcomes can be achieved. Structured leg ulcer assessment leads to diagnosis, and diagnosis leads to correct treatment or referral. Even an uncertain diagnosis is of benefit as this should prompt a referral to a practitioner who can make a diagnosis. Get patients involved, recognise their knowledge and experience and use it to create a workable treatment solution.
  
References
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2. Royal College of Nursing (RCN). Clinical Practice Guidelines. The Management of Patients with Venous Leg Ulcers 2006. London: RCN; 2006.
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4. Margolis DJ, Berlin JA, Strom BL. Risk factors associated with the failure of a venous leg ulcer to heal. Arch Dermatol 1999;135:920-6.
5. Drew P, Posnett J, Rusling L; Wound Care Audit Team. The cost of wound care for a local population in England. Int Wound J 2007;4(2):149-55.
6. Marston W, Vowden K. Compression therapy: a guide to safe practice. In: European Wound Management Association (EWMA). Position Document: Understanding Compression Therapy. London: MEP Ltd; 2003.
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8. World Union of Wound Healing Societies (WUWHS). Compression in venous leg ulcers: a consensus document. London: MEP Ltd; 2008.
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11. Barwell JR, Taylor M, Deacon J et al. Surgical correction of isolated superficial venous reflux reduces long-term recurrence rate in chronic venous leg ulcers. Eur J Vasc Endovasc Surg 2000;20(4):263-8.