Venous leg ulcers: treating a chronic condition

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Venous leg ulcers: treating a chronic condition XXX

Cause of VLUs The venous system is made up of long deep veins, superficial and perforator veins, which have non-return valves. When a person walks or stands, venous blood in the lower legs needs to be pumped back into the venous system to the heart against gravity. Blood is squeezed upwards as muscles in the calf, thighs and feet contract and the negative pressure produced in the thorax when the person inhales, also aids venous return to the heart. In order to stop the blood flowing back as a result of gravity, the non-return valves close as the calf muscle relaxes (Muldoon, 2013; Wounds International, 2013). The efficiency of this process is dependent therefore on a fully

Annmarie Brown Lecturer in Nursing, School of Health and Human Science, University of Essex [email protected]

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functioning calf muscle pump, as this is one of the major anatomical structures involved. As a result of the ageing process, or other risk factors, such as having had a deep vein thrombosis (Lindholm, 2002), a sedentary lifestyle or being overweight (Green and Mason, 2006; Wounds International, 2013), these valves become ‘floppy’ and allow some blood to back-flow, resulting in abnormally high blood pressure, called venous hypertension, within the veins of the lower legs. This is further increased if the patient has poor ankle mobility or an abnormal gait, as the calf muscle no longer pumps the blood effectively. zz Signs of venous hypertension include: zz Prominent varicose veins zz Dark staining around the gaiter areas of the leg (lipodermatosclerosis) as a result of red blood cells leaking into tissues. This is due to pressure and induration, which is when the skin develops a hard ‘woody’ texture as the haemosiderin deposits build up in the tissues (Muldoon, 2013) (Figure 1). Further signs include atrophy blanche, which presents as a white speckled area on the lower leg and foot, as a result of pigmentation loss, which can be very painful. Ankle flare is the name for the commonly observed patches of purplish thread veins in the ankle area, and although this is considered to be an early sign of venous disease, the presence of ankle flare does not indicate that an ulcer is inevitable (Muldoon, 2013). Finally, the resident may have swollen legs as a result of the blood vessels stretching and allowing protein-rich fluid into the interstitial spaces (Muldoon, 2013). This underlying condition may not manifest itself until the resident suffers a minor injury to their leg which does not heal and finally forms a venous leg ulcer. The precise mechanism of why this happens is not fully understood.

Treatment strategies Surgery has been found to be effective in venous hypertension; however, as many patients tend to be older; this is often not the preferred choice of treatment (Margolis et al, 2002; Dix et al, 2005; Gohel et al, nRC | May 2016, vol 18, no 5

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t has been estimated that between approximately 70 000 to 190 000 people living in the UK have a venous leg ulcer (VLU) (Posnett and Franks, 2007; Augustin et al, 2014). Since the majority of these are older people (Gottrup et al, 2001; Moffatt et al, 2003), it is quite likely that health professionals working in care homes will encounter residents with this condition. This article will give a brief overview of the cause of venous leg ulcers (VLUs), treatment options and strategies to aid healing of this chronic condition. An overview of the main treatment strategy—compression therapy will be discussed; however, it is not the intention of this article to teach the application of compression, as this requires specialist training.

CLINICAL REVIEW

2007). The most commonly used treatment is graduated compression therapy which is regarded as the ‘gold standard’ (O’Meara et al, 2012). Compression therapy works by applying an external force to the skin, forcing the blood back up into the veins against gravity; thus promoting normal upward flow of venous blood and reducing the high pressure to the lower limbs. As a result, improved venous and lymphatic return reduces swelling to the lower limbs, reduces exudate, reduces pain, promotes healing and improves skin condition (Muldoon, 2013).

Types of compression therapy Bandages


There are broadly two main types of compression therapy—bandages and hosiery. Bandages can be either longstretch elastic (Figure 2) or short-stretch elastic (Figure 3). Long-stretch elastic bandages are applied in layers and are capable of delivering a consistently high level of compression over a 24-hour period, whereas shortstretch bandages deliver high pressures when the patient is mobile (high working pressures), with very little pressure when the patient is at rest (low working pressures) (Muldoon, 2013). These bandages are generally supplied in a kit form and sized according to the patient’s ankle circumference. The application of compression bandages must only be performed following holistic assessment, including vascular studies by practitioners who have undergone specialist training in assessment and application. This is because inappropriate application of compression to limbs where the circulation is already compromised can have disastrous consequences, including amputation of the affected limb (Figure 4).

Figure 1. Lipodermatosclerosis

Compression hosiery

Caring for residents with compression hosiery

Compression hosiery is a particularly useful and effective alternative when there is a lack of trained staff to apply bandages, and is popular with many patients who may not be able to tolerate bandages (Muldoon, 2013). Hosiery designed for leg ulcer healing is generally supplied in kit form and can be used when the ulcer is small, has very little exudate and the resident’s legs are not swollen (Figure 5). They can also promote independence if the resident is able to apply and remove them themselves (Mosti, 2012). Compression hosiery has also been found to be effective in preventing ulcer recurrence. A study found that recurrence at 6 months was 46%, compared to 21% when patients wore class 3 compression hosiery (Vandongen and Stacey, 2000). This is a very strong type of compression; however, and many older people would be unable to tolerate this. Subsequently, a lower level of compression may be prescribed for prevention to achieve concordance.

Applying and removing compression hosiery can be undertaken by any member of staff, as long as the necessary assessments have been carried out by trained staff. The principles of caring for a resident with compression hosiery are: zz Application can be difficult. There are several aids available to help with application. If these are not available, rubber gloves with easi-grip features can help, although latex allergy must be ruled out first zz Ensure you remove the hosiery at bedtime if at all possible. This is because compression hosiery delivers consistent pressure over 24 hours, and removal allows the resident’s skin to breathe and may aid comfort in sleeping zz Ensure you reapply the hosiery first thing in the morning; preferably while the resident is still in bed. This will prevent the legs swelling, particularly if the legs are allowed to be in a dependent position for the rest of the day

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zz After taking the hosiery off at night time, apply a good

quality bland emollient to the legs, for example, 50% w/w liquid paraffin and 50% w/w white soft paraffin. This should be applied in the direction of the hair growth, avoiding circular or rubbing movements, which can cause folliculitis. Applying this at night will enable the emollient to be absorbed and will not affect the fabric of the hosiery zz Check the hosiery for wear and tear at every application. Hosiery generally is guaranteed for 3 months; however,it may need to be replaced if the resident gains or loses weight zz If the hosiery has been prescribed for the first time, it is essential to check the circulation. Excessive pain or a dusky colour to the toes may indicate compromised circulation and the hosiery should be removed immediately. The prescriber needs to be advised as soon as possible zz If the resident has an open leg ulcer and the hosiery has been prescribed for healing, check that the dressing is intact and is appropriate for the level of exudate zz Encourage the resident to mobilise for periods during the day to encourage calf muscle pump action. In addition, periods of leg elevation with a foot stool or on the bed will also encourage healing and reduce any swelling that may build up during the day zz Exercises, such as heel raises, toe curls and calf stretches when standing have been found to aid calf muscle function and should be encouraged (Brown, 2012).

The single most important factor in healing venous leg ulcers is the application of graduated compression therapy (O’Meara et al, 2012). VLUs with high exudate levels are generally better managed with compression bandaging where an absorbent padding layer is supplied as part of the kit. The efficacy of some dressings designed to manage heavy amounts of exudate may be reduced under compression bandaging, particularly if they rely on moisture vapour transmission to manage the exudate [AQ 1. A short explanation of MVT may be useful] (Muldoon, 2013). As a general rule, a simple, non-adherent contact layer may be the most appropriate dressing to use For VLUs being managed with compression hosiery, the type of dressing applied will depend on the condition of the wound bed, the aim of treatment and the wear time, for example, foams and hydrocolloids. Practitioners need to be mindful, however, that adhesive dressings should be used with caution as the force of the compression may increase their adhesive properties, making removal difficult (Muldoon 2013).

Conclusion Given the numbers of people suffering with VLUs, It is likely that staff in residential and care homes will be re200

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Wound dressings for venous leg ulcers

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Key points zz Patients with venous leg ulcers (VLUs) need to be

assessed by specially trained staff zz Compression bandages must only be applied by

trained practitioners; however, compression hosiery can be managed by any member of the nursing staff zz Compression hosiery can be used for healing and prevention of recurrence zz Residents should be encouraged to perform activities, such as foot exercises to aid healing zz VLUs are healed by the use of compression therapy; wound dressings are of secondary importance

quired to care for patients having treatment for VLUs. If residents have been prescribed compression bandages, it is essential that their care is managed by nurses who have undertaken specialist training. More frequently; however, compression hosiery is now being used, not only to prevent, but also to heal VLUs. This brief article has discussed the underlying causes of VLUs, different types of compression and has given some tips for all levels of staff that may care for residents in compression hosiery. nRC


This article has been subject to double-blind peer review. Augustin M, Brocatti LK, Rustenbach SJ et al (2014) Cost-of-illness of leg ulcers in the community. Int Wound J 11(3): 283-92. doi: 10.1111/j.1742481X.2012.01089.x Brown A (2012) Life-style advice and self-care strategies for venous leg ulcer patients: what is the evidence? J Wound Care 21(7): 342–50 Dix FP, Picton A, McCollum CN (2005) Effect of superficial venous surgery on venous function in chronic venous insufficiency. Ann Vasc Surg 19(5): 678–85 Gohel MS, Barwell JR, Taylor M, Chant T, Foy C, Farnshaw JJ et al (2007) Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ 335(7610): 83 Gottrup F, Holstein P, Jorgensen B et al (2001) New concept of a multidisciplinary wound healing center and a national expert function of wound healing. Arch Surg 136(7): 765–72 Green T, Mason W (2006) Chronic oedema, identification and referral pathways. 11(Suppl 4): S8–16 Lindholm C (2002) DVT: the forgotten factor in leg ulcer prevention. J Wound Care 11(1): 5 Margolis DJ, Bilker W, Santanna J, Baumgarten M (2002) Venous leg ulcer: incidence and prevalence in the elderly. J Am Acad Dermatol 46(3): 381–6 Muldoon J (2013) Chronic ulcers of the lower limb. In: Flanagan M (2013) (ed) Wound Healing and Skin Integrity. Principles And Practice. Wiley-Blackwell, Sussex Moffatt CJ, Franks PJ, Doherty DC et al (2003) Lymphoedema an underestimated health problem. QJM 96(10): 731–8 Mosti G (2012) Elastic stockings versus inelastic bandages for ulcer healing is a fair comparison. Phlebology 27(1): 1–4. doi: 10.1258/ phleb.2011.011e06 O’Meara S, Cullum N, Nelson EA, Dumville JC (2012) Compression for venous leg ulcers. Cochrane Database Syst Rev (1): CD000265. doi: 10.1002/14651858 Posnett J, Franks P (2007) The cost of skin breakdown and ulceration in the UK. In: Pownall E (ed) Skin Breakdown: The Silent Epidemic. Smith and Nephew Foundation, Hull Vandongen Y, Stacey M (2000) Graduated compression elastic stockings to reduce lipodermatosclerosis and ulcer recurrence. Phlebology 15(1): 33–7. doi: 10.1177/026835550001500106 Wounds International (2013) Principles of compression in venous disease: a practitioner’s guide to treatment and prevention of venous leg ulcers. Wounds International. http://bit.ly/1H07eHh (accessed 16 March 2016)

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