Chronic non-healing venous ulcer wounds are an economic burden to the health care system and are the most common type of leg ulcer, affecting around 1% of the population, with 3% of people aged over 80.¹ With obesity and diabetes on the rise, the burden is likely to continue to increase. Lowered quality of life, amputation, and death are often the results of venous leg ulcer chronicity, and the rate of recurrence within three months after wound closure has been reported to be as high as 70%.²

Venous Leg Ulcer Prevention

Venous leg ulcers can be prevented by addressing many known risk factors, such as losing weight, increasing activity, maintaining a well-balanced diet, adhering to good skin care, smoking cessation, and wearing compression stockings as ordered. The majority of people at risk are those who have had a previous venous leg ulcer. Varicose veins that are not treated are also at increased risk of ulcers. Surgical repair of the damaged veins or removal of the affected veins entirely is encouraged. Compression stockings should be replaced every three to six months because they lose elasticity; try suggesting to your patients that they mark the date on their calendars. For patients who are non-ambulatory, suggest ankle exercises such as circling their ankles both directions or doing pedal pushes; elevating legs above the heart is also helpful. Eating a well-balanced diet and losing weight are key to prevention because of the extra pressure on the legs.

Health Economic Impact of Chronic Venous Ulcers

There is a large population of people across the globe with chronic venous insufficiency leading to venous leg ulcers. It is estimated 500,000-600,000 people have venous leg ulcers in the United States. The annual US cost is a heaping 1 billion dollars, and in the United Kingdom it is 400-600 million pounds. There is a variety of treatments used to treat venous leg ulcers, with compression being the first-line conventional therapy. Surgery, sclerotherapy, and adjuvant pharmacotherapy are other treatment modalities used.³

Prevention and Treatment of Recurrence of Venous Leg Ulcers

Recurrence of venous leg ulcers imposes an economic strain on the health care system. Therefore, treatment strategies should be evidenced based, but also cost-effective. Compression is widely used as the first line of treatment.⁴ Compression dressings range from two to five layers of material, often with a gauze or foam base and various short-stretch (also called high-stiffness) materials. It should be applied from the base of the toes to approximately two finger widths below the popliteal space, with some conditions requiring thigh-level compression.⁵ Short stretch (high-stiffness) graduated compression is considered the best for those without significant PAD (graduated compression is highest at the ankle and decreases proximally).

Some recent expert recommendations suggest a negative gradient with compression tightest at the calf where most of the pressure is required for blood return, though this requires more research and is not widely practiced.^{6, 7} Patients who have low calf muscle pump activity secondary to limited ankle mobility or are non-ambulatory may benefit from other types of compression or pneumatic compression.⁸ Permanent therapeutic compression garments come in multiple varieties, including Velcro®, zip, and dual layer options. Venous leg ulcers pose a major challenge that warrants using a variety of treatment regimens that will ensure the best outcomes without recurrence. Variations of practice and evidence across the globe contradict each other. This causes uncertainty and creates hurdles in seeking treatment and implementing guidelines or services.

Global Recommendations

There is an array of venous leg ulcer management strategies across the globe. Some are controversial, and there is not a substantial amount of evidence-based research. The list includes:

• Wound cleansing or washes with chemical, antimicrobial, antiseptic, surfactant agents
• Dressing and topical agents
• Debridement methods
• Compression
• Protease-modulating matrix (PMM) treatments
• Oral medications
• Anticoagulant therapy
• Systemic antibiotics
• Oral nutritional supplements
• Surgical interventions
• Electromagnetic therapy
• Therapeutic ultrasound
• Skin grafting

Conclusion

What we do know is that compression can help reduce rates of recurrence when compared with no compression. Early diagnosis, intervention, and prevention are most effective in venous ulcer complications and recurrence. Utilizing dressings that provide optimal moisture, using topical agents, evaluating circulation before graduated compression, performing debridement, and including the patient in the plan of care will optimize best outcomes.

References

1. Franks PJ, Barker J, Collier M, et al. Management of patients with venous leg ulcers: challenges and current best practice. J Wound Care. 2016;25 Suppl 6:S1–67.

2. Gethin G, Killeen F, Devane D. Heterogeneity of wound outcome measures in RCTs of treatments for VLUs: a systematic review. J Wound Care. 2015;24(5):211–2, 214, 216 passim. [Erratum in J Wound Care. 2015;24(10):484.]

3. Simka N, Majewski E. The social and economic burden of venous leg ulcers: focus on the role of micronized purified flavonoid fraction adjuvant therapy. Am J Clin Dermatol. 2003;4(8):573–81.

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

5. Principles of compression in venous disease: a practitioner's guide to treatment and prevention of venous leg ulcers. Wounds International, 2013. Available from: http://bit.ly/1QXfA9W

6. Couch, K., Gould, L., et al. The International Consolidated Venous Ulcer Guideline Update (2015): Process Improvement, Evidence Analysis, and Future Goals. Ostomy Wound management. 2017 May 1;volume 63(5):42-46.

7. O'Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database Syst Rev 2012; 11: CD000265

8. Harding, K. Simplifying venous leg ulcer management: consensus recommendations. Wounds UK. 2015. Available from: https://www.wounds-uk.com/resources/details/simplifying-venous-leg-ulce… [Accessed January 9, 2019].

Suggested Reading Chapman S . Venous leg ulcers: evidence review. (written for the British Journal of Community Nursing, 2017.) http://www.evidentlycochrane.net/venous-leg-ulcers-evidence/. Accessed December 30, 2018.