Published on 18/03/2015 by admin
Filed under Dermatology
Last modified 22/04/2025
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Eri Fukaya and David J. Margolis
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
In general, leg ulcers are slow to heal. These wounds are on the most distal aspects of the circulatory, lymphatic, and nervous system supply and as a result there are routes for collateral vessel formation. The lower extremities are also the bearers of weight and gravity. Arterial and venous problems, infection, trauma and systemic problems such as diabetes, immunodeficiency, malnutrition or medications add to impairment. Leg ulcers secondary to other causes such as infection, basal or squamous cell cancer, or pyoderma gangrenosum can also occur but are discussed elsewhere.
All chronic wounds are contaminated but not necessarily infected. Many feel that infection can be optimally treated by debridement, which is the removal of slough and necrotic tissue to prevent and/or contain infection as well as minimizing the presence of inflammatory materials. Wound infections prolong inflammation by maintaining high levels of proinflammatory cytokines and tissue proteases. These degrade granulation tissue and delay collagen deposition and healing. Debridement and aggressive cleaning can be done mechanically with curettage, with a scissor or with a scalpel. It can also be accomplished with pressurized liquids, ultrasound, biomechanically (i.e., maggots), and enzymatically.
Wound dressings should be chosen to address exudate control, wound protection, and pain relief. The frequency of dressing changes is dependent on the dressing and the reason for its use. The goal is to provide a moist wound environment to promote epithelialization. Wound exudates contain vital proteins and cytokines which facilitate autolytic debridement and promote healing. Using hydrocolloids, hydrogels, alginates, transparent films, and other bandages provide coverage and may promote the function of these enzymes. However, excessive exudate can saturate the wound bed diminishing these beneficial properties as well as macerate surrounding tissue making it more prone to injury. Finally, choosing a dressing that does not adhere to the wound bed can be important to assure that it does not disrupt re-epithelialization when it is removed.
Accurately identifying the key cause of wounds is essential in the management of leg ulcers though many wounds are complex and may be of more than one etiology. Below are specific approaches to different leg ulcers.
Venous insufficiency caused by venous reflux and/or deep venous thrombosis (DVT) is a cause of ambulatory venous hypertension, which may lead to venous leg ulcers. The diagnosis for superficial or deep venous abnormality can be with a duplex ultrasound, but may also be apparent on clinical examination. If there is a high clinical suspicion for a pelvic DVT, a CT venogram should be performed.
Calf muscle pump function is critical for venous outflow thus venous ulcer management hinges on good lower limb compression. The use of compression bandages for venous leg ulcer has been carefully studied and is the standard care. For prevention, it is recommended that patients wear graduated compression stockings. Leg elevation and weight reduction reduce swelling severity.
Ulcers can be caused by chronic limb ischemia. Most of the affected individuals have peripheral artery disease and many have diabetes. Those with diabetes tend to have involvement of smaller arterioles. Lower limb ischemia causes pain and limb pallor. Arterial circulation can be evaluated non-invasively with ankle brachial index (ABI) and pulse volume recordings (PVR). The PVR may be non-diagnostic in patients with advanced calcification such as those with diabetes. In this setting a duplex ultrasound or CT angiography is necessary. Treatment including proximal obstructive lesions causing ischemia may require invasive interventions such as angioplasty or arterial bypass grafting. Patients with poor arterial circulation can develop deep soft tissue infection, osteomyelitis, or gangrene leading to amputation, thus close monitoring is essential.
Unperceived trauma and/or pressures can lead to wounding and ulcer formation in diabetic neuropathy. A 5.07 Semmes–Weinstein monofilament can be used to test for protective sensation and a 128-Hz tuning fork placed at the base of the great toenail can test for vibratory sensation. Deep tendon reflexes are commonly hypoactive or absent with diabetic neuropathy.
Pressure ulcers most often occur in patients with limited mobility such as bed-ridden elderly patients or those with spine or brain injury, and are most commonly seen in areas bearing weight from sitting or lying over a bony prominence close to the surface of the skin such as the sacrum or trochanter. Efforts should be aimed at off-loading the affected area.
Compression therapy or off-loading
Antibiotic – not necessary in most cases
Arterial reconstruction
O’Meara S, Cullum NA, Nelson EA. Cochrane Database Syst Rev 2009; 21(1).
Compression increases ulcer healing rates compared with no compression. Multi-component systems are more effective than single-component systems. Multi-component systems containing an elastic bandage appear more effective than those composed mainly of inelastic constituents.
O’Meara S, Al-Kurdi D, Ologun Y, Ovington LG. Cochrane Database Syst Rev 2010; 20(1).
No evidence supports routine use of systemic antibiotics. However, lack of evidence does not mean that it is ill advised. Recommendations are that antibacterial preparations should only be used in clinical infections. There is some evidence for cadexomer iodine use topically.
Treiman GS, Oderich GS, Ashrafi A, Schneider PA. J Vasc Surg 2000; 31: 1110–18.
Successful arterial reconstruction, especially a patent posterior tibial artery after bypass, is effective in treating most heel ulcers or gangrene. Patients with impaired renal function are at increased risk for failure of treatment, but their wounds may successfully heal and should not be denied revascularization procedures.
Ablation of incompetent superficial and perforator veins
Oral pentoxifylline
Harlander-Locke M, Lawrence PF, Alktaifi A, Jimenez JC, Rigberg D, DeRubertis B. J Vasc Surg 2012; 55: 458–64.
Significant reduction in ulcer size and ultimate healing following ablation of incompetent superficial and perforator veins in patients who have failed conventional compression therapy.
Nelson EA, Prescott RJ, Harper DR, Gibson B, Brown D, Ruckley CV. J Vasc Surg 2007; 45: 134–41.
Pentoxifylline increased the proportion healing compared with placebo similar to other systematic reviews, although this finding was only statistically significant when a secondary adjusted analysis was conducted.
Bus SA, Valk GD, van Deursen RW, Armstrong DG, Caravaggi C, Hlavácek P, et al. Diabetes Metab Res Rev 2008; 24(Suppl 1): S162–80.
The evidence to support the use of footwear and surgical interventions for the prevention of ulceration is meager. Evidence was found to support the use of total contact casts and other non-removable modalities for treatment of neuropathic plantar ulcers.
Taylor SM, Johnson BL, Samies NL, Rawlinson RD, Williamson LE, Davis SA, et al. J Am Coll Surg 2011; 212: 532–45.
Revascularization is effective treatment for ischemia, but may be overvalued compared to improvement afforded by better medical foot wound management.
Hyperbaric oxygen therapy for diabetic foot ulcers
Cell-based therapy*
*Growth factors and stem cells are responsible for cell migration, division, differentiation, and protein expression during wound healing. Many agents are undergoing investigation but the only available product proven to be efficacious in randomized, double-blinded studies is platelet-derived growth factor (PDGF), available as recombinant human PDGF-BB. Other cytokines under study include transforming growth factor beta (TGF-β), epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), and insulin-like growth factor (IGF-1).
Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE. Cochrane Database Syst Rev 2012; 18: 4.
In people with foot ulcers due to diabetes, hyperbaric oxygen therapy significantly improved the ulcers healed in the short term but not the long term. However, the trials had various flaws in design and/or reporting so the results may not be accurate.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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