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Modern management of venous and arterial leg ulcers

Christine Moffatt
MA RGN NDN
Professor of Nursing and Educational Director
Centre for Research and Implementation of Clinical Practice
Thames Valley University
Ealing, London

Leg ulceration affects around 1% of the adult population, with the prevalence rising with age.(1,2) It is associated with considerable morbidity and reduced quality of life.(3) The majority of ulcers in Western populations are caused by venous or arterial disease (see Table 1).

[[NIP02_table1_150]]

Assessment
Assessment requires a holistic approach that seeks to understand the impact that leg ulceration has on the patient and family as well as properly defining the aetiology to ensure correct treatment. Simple differential diagnosis of venous and arterial disease can generally be performed by using previous medical history, signs and symptoms, and simple procedures such as recording an ABPI (ankle/brachial pressure index) using Doppler ultrasound.(4) More complex investigations - Duplex ultrasonography and angiograms - will be required to determine the extent of the disease in patients with ischaemia or those requiring venous surgery.
Other routine investigations should include full blood screen including random glucose. Rheumatoid factor and antinuclear studies may be required if more complex disease is suspected. Wound swabs are not routine and are required only if there are symptoms of cellulitis.
It is important to gain a perspective on factors that influence ulcer healing. Assessment should examine the presence of concurrent illness, particularly other cardiovascular disease. Factors such as the length of ulceration and the mobility status of the patient have been found to affect healing.(5) Careful assessment of the stage of wound healing and size of wound using wound mapping and surrounding skin are important in helping to decide on choice of dressings and compression therapy.
Understanding the patient's perspective of the ulcer is central to care and it is important to carefully assess pain and analgesic usage. Pain has not been traditionally associated with venous ulceration. However, recent research has shown that up to 80% of patients experience pain. Issues such as odour and exudate control may be of vital importance to patients, who may become socially isolated if their ulcer is detectable to others.

Treatment priorities
Irrespective of the type of ulcer the patient has, a ­number of treatment priorities are common to all:

  • Correct the underlying problem, for example ­revascularisation in peripheral vascular disease, or reverse venous hypertension by applying ­compression.
  • Select appropriate skin and wound management strategies.
  • Prevent avoidable complications that may inhibit healing.
  • Improve wider factors that impact on outcome, such as medical and nutritional status.
  • Provide psychological support to the patient and ­their family.
  • Prevent recurrence when the ulcer heals.

Skin and wound care
Current best practice recommends simple cleansing of the wound avoiding powerful antiseptics. Immersion of the limb into warm water and use of an emollient to aid skin hydration may leave the patient feeling "clean" and assist with removing offensive odour and exudate, and in debridement. Emollients help to maintain the skin's barrier function and prevent infection. Topical steroids may be applied to severe varicose eczema or if contact dermatitis is suspected. Particular care should be taken in patients with peripheral vascular disease. Toe webs and nail beds should be checked for signs of infection or for gangrene developing in severe peripheral vascular disease. Leg ulcers are heavily colonised with a range of ­bacteria. Patients with ischaemia and diabetes are ­particularly prone to infection, which may have ­catastrophic consequences on tissue viability. Antibiotics are frequently required prophylactically in these patients but should be avoided in patients with venous ulceration unless the patient has concurrent lymphoedema, which may require ­prophylaxis with benzylpenicillin.

Choice of wound dressings
A wide range of wound dressings are available. However, inadequate research makes it impossible to accurately state that one type is superior to another. The concept of creating a moist wound environment is now broadly accepted.(6) Patients with venous ulceration frequently have copious exudate. Selection of appropriate dressing such as foam and alginate are important in preventing maceration from poor exudate management.

Management of venous ulceration
The primary aim of management is to reverse the effect of venous hypertension. Application of high compression has a number of haemodynamic and inflammatory effects, although these are poorly understood. The external compression helps to ­counteract the high pressure in the superficial veins and improves overall venous ­function. This reduces the inflammatory processes occurring in the damaged microcirculation due to cyclical periods of leg dependency. A literature review shows that higher compression (approximately 35-40mmHg pressure at the ankle) is more effective than lower levels.(7) It is important to ensure elimination of arterial disease before application. High compression is currently recommended for all patients with an ABPI >0.8 (see Table 2). Compression can also be applied using different ­methods of bandaging or with elastic hosiery and intermittent pneumatic ­compression - ­applying cycles of controlled pressure to a limb using compressed air.

[[NIP02_table2_152]]

Other treatment methods
A number of skin grafting techniques are used in ulcer healing, including meshed skin grafting and pinch grafting, which can be undertaken by nurses using local anaesthetic. Novel treatments include the use of skin equivalents, although these are expensive. To avoid rejection following grafting, infection, particularly ­haemolytic streptococci and pseudomonas, must be avoided. Patients with venous ulceration must receive compression before they begin mobilising or else the graft will fail.

Management of arterial and mixed aetiology
The priority here is to determine the degree of ischaemia. If it is severe, reconstructive surgery or angiologic procedures such as angioplasty may be needed to improve circulation before healing may occur. Patients with some arterial involvement may ­tolerate reduced compression. However, signs and symptoms between patients vary. Some with fairly minimal levels of compression find the pain intolerable; others with severe disease manage well. Patients with significant degrees of ischaemia (ABPI >0.5) should not receive compression. They require carefully monitored use of regular opiates. They are at risk of superseding infection leading to gangrene. Patients with conditions such as diabetes and rheumatoid disease may have microvascular arterial disease and should receive compression only under expert nursing or medical supervision.

Conclusion
Effective treatment of leg ulceration requires that patients have a thorough understanding of the aims of treatment. When healing occurs, appropriate prevention strategies such as elastic hosiery and regular follow-up should be put in place.
Helping the patient to modify their lifestyle is an important part of treatment. Health education advice must be realistic and focused on the needs of the individual. The practitioner must remain realistic in their expectations while maintaining an optimistic outlook.

References

  1. Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and prevention of care. BMJ 1985;290:1855-6.
  2. Cornwall JV, Dore CJ, Lewis JD. Leg ulcers: epidemiology and aetiology. Br J Surg 1986;73:693-6.
  3. Franks PJ, Moffatt CJ, Connolly M, et al. Factors associated with healing leg ulceration with high compression. Age Ageing 1995;24:407-10.
  4. Moffatt CJ. Issues in the assessment of leg ulceration. J Wound Care 1998;19:469-73.
  5. Franks PJ, Oldroyd MI, Dickson D, Sharp EJ, Moffatt CJ. Risk factors for leg ulcer recurrence: a randomised ­clinical trial. Age Ageing 1995;24:490-4.
  6. Winter GD. Formation of the scab and the rate of epithelialisation of superficial wounds in the skin of the young domestic pig. Nature 1962;193:293-4.
  7. Fletcher A, Cullum N, Sheldon TA. A systematic review of compression treatment for venous leg ulcers. BMJ 1997;315:576-80.

Resources
Wound Care Society
W:www.woundcaresociety.org

Tissue Viability Society
W:www.tvs.org.uk