|HOW I DO IT
|Year : 2020 | Volume
| Issue : 3 | Page : 265-269
Venous ulcer management: Frontier unconquered
Edwin Stephen1, Vimalin Samuel2
1 Division of Surgery, Vascular Surgery Unit, Sultan Qaboos University Hospital, Muscat, Oman
2 Department of Vascular Surgery, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||28-Apr-2020|
|Date of Acceptance||05-May-2020|
|Date of Web Publication||12-Sep-2020|
Division of Surgery, Vascular Surgery Unit, Sultan Qaboos University Hospital, Muscat
Source of Support: None, Conflict of Interest: None
Every vascular surgeon or physician involved in ulcer care aims at healing an ulcer as soon as possible and recurrence is a dreaded reality that they have to face. There are several adjuncts to surgery that aid healing. A lot needs to be done and known about– what are the options available beyond surgery that expedite healing and prevent recurrence? This is frontier that is yet to be conquered.
Keywords: Bilayer, compression, honey, management, skin graft, sugar, surgery, ulcer, venous
|How to cite this article:|
Stephen E, Samuel V. Venous ulcer management: Frontier unconquered. Indian J Vasc Endovasc Surg 2020;7:265-9
| Introduction|| |
Studies from India about the prevalence of venous leg ulcers (VLU) are limited. A study published in 2005 estimated the prevalence of chronic wounds in India to be 4.5/1000 population. The incidence of acute wounds was more than double at 10.5/1000 population. In a descriptive, cross-sectional study about the clinical profile of VLU, it was found that they were frequent in the economically productive age group (36–45 years); with a male preponderance (M: F – 8.4:1). The prevalence values quoted in literature across the globe may not be accurate, as most are “point prevalence” studies, which quote a lower percentage 0.02%-1% and not “period prevalence” which is higher at 1%–5%.
The etiology for VLU in the Caucasian population is venous hypertension, peripheral arterial occlusive disease, neuropathy secondary to diabetes, vasculitis or a combination of these. In India, tuberculosis, filariasis, leprosy, improperly treated acute wounds; myths and superstitions of patients must also be on the radar.,
Regardless of the cause VLU's have a negative impact on the psyche of the individual as a result of frequent hospital visits, recurrence of the ulcer, unemployment, and “social distancing,” when the ulcer is malodourous or oozy [Figure 1].
Majority of the Indian population is uninsured and have to bear the cost of treatment “out of pocket.” These constitute 68% and 75% in rural and urban households respectively. Government supported schemes insure about 13% of the rural and urban population, as against 1% and 6% being covered by the employer or self-sponsored health insurance, respectively.
Therefore, there is a pressing need to find therapeutic options beyond surgery, which will expedite healing and prevent recurrence.
| Back to Basics|| |
A good and thorough history with examination is the foundation of optimal care. History of previous leg swelling, medications consumed, systemic ailment/s, treatment modalities used elsewhere is essential. Every examination must document-Body Mass Index, nutritional status, and peripheral pulse chart. Examination of the groin and infra-umbilical region for signs of chronic venous obstruction such as dilated veins over the abdominal wall, intravenous drug use [Figure 2], besides signs of phlebo-lymphedema [Figure 3].
|Figure 2: Scars of intravenous drug use in the groin (Courtesy Dr. Marjan, Iran)|
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| Nonoperative Therapeutic Options|| |
The options available to manage VLU's are mentioned below amongst others
- Compression therapy – remains the mainstay of treatment
- Medications – Flavonoids, pentoxifylline, horse chestnut seed extract, calcium dobesilate
- Dressings – Alginate, skin graft; Topical creams
- Nutrition – Manage malnutrition/obesity
- Improve the range of ankle movement
- Hyperbaric oxygen therapy
- Negative pressure wound therapy
- Electromagnetic/ultrasound therapy
| Challenges to Compliance With Compression|| |
Compression therapy is the main component in treating VLU's. A Cochrane review in 2012 of 48 RCT's, concluded that compression increased ulcer healing rate with a multi-component system being more effective than single-component. Two-layer bandaging (2 LB) was as effective as four layer bandaging (4 LB). Short stretch bandaging was not as effective as 4 LB.
Some of the challenges that clinicians face are:
- Compliance – As a consequence of the difficulty in putting on and taking them off; heat; humidity; too tight; allergy and cost
- Lack of availability of standard/custom made hosiery
- Patients with peripheral arterial disease
- Co-morbidities such as congestive cardiac/liver/renal failure
- Removal to wash feet before prayers – in some patients up to 5 times a day.
| What is the Solution?|| |
Some compression is better than NO compression. Clinicians need to “tailor” the compression that their patients can tolerate and enhance compliance.
Arguably the option that can overcome most of the factors associated with patient compliance is manual decongestive therapy or manual lymphatic drainage. This was ratified in a study of thirty-eight patients with VLU from Vellore, India [Figure 4]. This modality requires the patient and caregiver to undergo training for about 30 minutes a day for 3-5 days, depending on how quickly they learn the technique. It is low cost, reproducible yet effective.
|Figure 4: Reduction of edema after 5 sessions of manual lymphatic drainage|
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For patients who find it difficult to don or remove compression stockings, there are stocking donner devices like “sock assist, Pivit Easy, sock slider,” available for purchase online [Figure 5].
Available adjustable compression wrap devices available like the AERO/CircAid Wrap [Figure 6] and [Figure 7] have velcro straps, which make application and removal much easier while providing sustained and stable compression. These devices are support patient independence and confidence with improved outcomes versus no compression. However, they do come at a price, which is dear to the end-user.
| What are Other Available Therapeutic Measures?|| |
- Reduced range of ankle movement results in poor calf pump function and delay in venous ulcer healing. If ankle movement is reduced, teach the patient active and passive ankle exercises, for example, heel lift, ankle circles/plantar and dorsiflexion/toe–heel walk and if possible refer them to a physiotherapist
- Sulodexide was found in a Cochrane review to improve ulcer healing when combined with local treatment of the VLU. The recommended dosing and diverse effects would require further studies
- In a study published in 2019 from Bengaluru on 47 patients with 50 VLU's, whose ulcers had not healed for 3 months, Prostaglandin E1 infusion was infused in a study at a dose of 500 mcg given over 5 days. These patients demonstrated faster healing rates and faster return to work
- Bi-layer artificial skin improved healing when combined with compression bandaging in comparison to simple dressing with compression
- New kids on the block – dehydrated sterile human amnion/chorion membrane allograft (Amcho Plast™) or acellular dermal matrix (DermACELL AWM) will require further studies before making recommendations. Clinicaltrials.gov (NCT 03589586) shows that recruitment is open for a multicentre, randomized, controlled, open-label trial comparing DermACELL AWM to wound dressings and multi-layer compression. The study is expected to be completed on September 30, 2020
- Obesity and venous hypertension are well associated, more so in female patients. Dietary/psychological advice and in some cases surgical intervention will improve healing of the VLU
- Sugar, when placed over an ulcer, is said to facilitate protein layer formation, provide an anti-microbial-osmotic action with a local nutrition supply, and reduce inflammatory edema. Rahul et al. in a prospective study that included 25 patients concluded that sugar was better than honey for dressing a chronic wound (includes VLU). Sugar is easy to store, apply, cost-effective, and improves ulcer healing
- The author has had, hitherto unpublished, favorable experience with the use of sugar in VLU when combined with 4 LB compression [Figure 8], [Figure 9], [Figure 10]
- A Cochrane review in 2015 was unable to give clarity on whether honey is good or bad for VLU. This was thought to be secondary to the heterogeneous patient and comparators that were studied and low quality of evidence
- Last but not least a need for good local hygiene with soap and water; baby brush to get rid of scaly skin, flakes of cream, and cleaning agents– peri-ulcer, pre dressing, cannot be over emphasized.
|Figure 10: Venous leg ulcers 6 weeks after sugar dressings and compression|
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| Conclusion|| |
It is true that “there are some things that money cannot buy.” One of them has to be the smile of a patient with a healed leg ulcer. Recurrence is a nightmare for the patient and physician. An evidence-based algorithm for treating VLU based on studies in the Cochrane database can be accessed by the reader. “One size will not fit all” and clinicians would have to modify treatment options based on what is available to them and the patient.
Future studies such as the use of human cellular matrix, topical application of growth factors, use of ulcer size measurement apps, and venous hemodynamics are on-going.
There is a need to reflect, share, and learn from each other while in-corporating findings from research and developing national/international guidelines to manage VLU's.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]