Venous ulcers pose a worldwide problem that comes with potential for high recurrence rates, risk of infection, and substantial treatment costs. Health care professionals must be knowledgeable about underlying causes and pathological features. Comorbidities often associated with venous ulcers contribute to these lesions and prolong healing times, which in turn can cause further complication. Venous disease and venous hypertension are lifelong conditions requiring lifelong management. The vicious cycle of venous reflux and obstruction associated with chronic venous disease can lead to ulceration(s). Management of venous ulcers requires comprehensive wound care and compression therapy for life.

Venous ulcers are known to be complex and costly. There is an array of evidence-based treatment options available to help formulate a comprehensive treatment plan toward wound closure. Health care professionals should utilize treatment options while encompassing a holistic approach to venous ulcer management. Involving the patient and/or caregiver in developing a treatment plan will increase the chances of successful wound healing outcomes. Wound closure is the primary goal of a treatment plan; however, preventing recurrence and infection should be considered just as important.

Evidence-Based Treatment Options

Compression Therapy

Compression therapy is considered the "gold standard" of care for venous ulcers. Compression therapy goals include edema management, venous reflux improvement, and enhanced healing.^1,2 Compression therapy can consist of 1 or more layers.³

• Elastic: bandages that conform to the size and shape of the leg.
• Inelastic: zinc oxide–impregnated gauze wraps such as an Unna boot.
• Dual compression: a compression method that combines elastic and inelastic bandage use simultaneously.
• Stockings or custom garments: can be knee-high, thigh-high, toes in or out. Patient preference should be considered when selecting a garment; 30mmHg to 40mmHg strength is preferred.^5,6
• Pneumatic compression pumps: 3 types of pumps that deliver variances of pressure gradient, inflation, and deflation cycles.⁴
• Leg elevation: increase deep venous flow and reduce venous pressure. Legs should be elevated above heart level.⁴

Advanced Wound Care Dressings

Wound care professionals should determine dressing selection by wound location, size, depth, exudate amount, bioburden or biofilm, frequency of dressing change, payer source or cost, and availability.⁴ Many dressings are available with or without antimicrobial properties such as silver or honey. Use as clinically indicated.

• Absorbent dressings: alginates, foams, and super absorbents; charcoal available for odor control
• Hydrocolloid: all shapes, sizes, and thicknesses; used as primary or secondary dressings
• Impregnated gauzes (low-adherence or non-stick): oil emulsion, petrolatum gauze, and bismuth gauze
• Collagen matrix: with or without silver

Antimicrobials and Antiseptics

Evidence has shown that cadexomer iodine, povidone-iodine, medical-grade honey, peroxide-based preparation, and silver are among options that may improve healing of venous ulcers.⁷

Wound Cleansers and Surfactants

Wound cleansers, surfactants, and solutions can help remove exudate, contaminants, and foreign debris in wound bed preparation. There are rinse and no-rinse formulas.

Advanced Wound Care Therapies

• Cellular and tissue-based products
• Skin grafting: used as secondary therapy for ulcers when standard care fails

Medications

The following medications may be part of a comprehensive treatment strategy for patients with venous disease:

• Pentoxifylline: hemorheologic agent that affects microcirculation and oxygenation⁴
• Aspirin (acetylsalicylic acid [ASA]): inconsistent evidence concerning benefits and harms of oral ASA in treatment of venous ulcers⁴
• Statins: vasoactive and anti-inflammatory effects⁴
• Phlebotomics: improves venous tone and decreases capillary permeability⁴
• Antibiotics: Systemic or topical and warranted only if infection is suspected⁴

Debridement Methods

Wound bed preparation has been shown to expedite healing rates. Using a debridement method can help move venous ulcers toward healing. Patients treated with sharp debridement at each physician’s office visit had significant reductions in wound size compared with those patients who didn't.⁸

• Biological: maggot therapy
• Enzymatic: such as, collagenase ointment
• Autolytic: moisture-retentive dressings such as hydrocolloid, transparent, and alginate dressings
• Mechanical: wet-to-dry dressings, whirlpool, pulse lavage
• Sharp debridement: using instrumentation such as a scalpel or curette (can be performed in the operating room (surgical debridement), in the clinic, or at the bedside)

Endovenous Intervention

Endovenous interventions include endovenous ablation, ligation, subfascial endoscopic perforator surgery, and sclerotherapy. Recent trials show faster healing rates of venous ulcers when early endovenous ablation to correct superficial venous reflux is performed in conjunction with compression therapy, compared with compression alone or with delayed intervention of an ulcer that has not reached wound closure after 6 months.⁹

Multidisciplinary Team Approach

The complexity of venous ulcer treatment warrants a team effort. It takes a multidisciplinary team approach to focus on various comorbidities and issues a patient may have. Utilizing a specialized team member will provide a comprehensive plan of care. Communication with each team member while focusing on a patient-centered approach is critical to preventing gaps in care. Working together, the team can move toward successful outcomes for their patients.

References

1. O'Donnell TF Jr., Passman MA, Marston WA, et al.; Society for Vascular Surgery; American Venous Forum. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg. 2014;60(2)(suppl):3S-59S.

2. Mauck KF, Asi N, Elraiyah TA, et al. Comparative systematic review and meta-analysis of compression modalities for the promotion of venous ulcer healing and reducing ulcer recurrence. J Vasc Surg. 2014;60(2)(suppl):71S-90S,e1-e2.

3. Hettrick H. The science of compression therapy for chronic venous insufficiency edema. J Am Col Certif Wound Spec. 2009;1(1):20-24.

4. Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Repair Regen. 2009;17(3):306-311.

5. Vandongen YK, Stacey MC. Graduated compression elastic stockings reduce lipodermatosclerosis and ulcer recurrence. Phlebology. 2000;15(1):33-37.

6. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2014;(9):CD002303.

7. O'Meara S, Al-Kurdi D, Ologun Y, et al. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 2014;(1):CD003557.

8. Bonkemeyer Millan S, Gan R, Townsend PE. Venous ulcers: diagnosis and treatment. Am Fam Physician. 2019;100(5):298-305.

9. Gohel MS, Heatley F, Liu X, et al.; EVRA Trial Investigators. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018;378(22):2105-2114.