Management of venous leg ulcers

CLEANSING AND EMOLLIENT THERAPY

Good skincare (washing and emollient therapy) is paramount in managing venous leg ulcers. Emollient therapy has two different modes of action:

• PASSIVE – emollients are lipids that occlude the skin surface, thus preventing water loss from the epidermis
• ACTIVE – Moisturisers are lipid emulsifiers that actively hydrate the skin by the application of a humectant to the surface of the skin.The active mode of action is the movement of water from the dermis to the epidermis

Emollients work to moisturise the skin by increasing the amount of water held in the epidermis. This occlusion for passive emollient therapy is achieved if greasy substances such as petrolatum are used. The active mode of action is the movement of water from the dermis to the epidermis. As the emollients increase the amount of water in the epidermis and make the skin less dry, they also have an anti-pruritic effect which is often beneficial to people wearing compression or hosiery.

The key aspect of skin care for the lower limb affected by venous disease and associated oedema is for the clinician to recognise underlying skin conditions, such as varicose eczema, lipodermatosclerosis or hyperkeratosis, and treat appropriately and continuously. The application of emollients will keep the skin supple and this regimen should ideally be continued indefinitely. Ointments are likely to produce fewer adverse reactions as they contain fewer sensitisers compared to lotions, gels and creams and therefore are a better choice in treating people with varicose eczema (moderate to strong potency topical steroids are also sometimes needed short term to treat the eczema).

Note to prescribers regarding Aqueous cream – sodium lauryl sulphate (SLS) (a component of aqueous cream) is a detergent and surfactant and has been used extensively for its thickening and emulsifying properties. However, recent studies have shown that it should not be used as wash product or leave-on emollient as it has potential to damage skin and compromise barrier function.

Further Reading

Best Practice in Emollient Therapy. A statement for healthcare professionals. December 2012

EWMA Statement 5.3.g: Concerning management of the surrounding skin, topical barrier preparations to reduce erythema and maceration from VLUs should be considered. Venous eczema can be treated with short-term topical steroids.

2. INFECTION IN VENOUS LEG ULCERS

Treatment of infection Statement 5.2.e: Bacterial swabs should not be taken routinely unless clinical signs of infection are present which include:

• New or increased wound pain
• Delayed healing
• Friable or hypergranulation tissue
• Increased heat
• Increased odour from the wound
• Increased white cell count
• Increased localised swelling
• Pyrexia

Before taking a wound swab, ensure the ulcer is cleaned with tap water.

The diagnosis of wound infection should be made on the clinical presentation and accompanying blood results. However if guidance on antibiotic prescribing is required the wound swab result will aid this decision making process.

The use of topical antibiotics is not recommended

Use of topical anti-microbial dressings are advocated for a local infection or prophylactically for a 2-week period for prevention in wounds at high risk (diabetic foot ulcers) for example, honey, silver, cadexomer iodine and PHMB.

Patients with infection should be followed up every 2-3 days until clinical improvement is seen. This would be suggested by reduction in inflammation, development of red healthy granulation tissue, reduction of exudate and pyrexia and pain..

If infection is not resolving, revisit the wound swab result and consider changing the antibiotic based on sensitivity recommendations. NICE guidance on leg ulcer infection and antimicrobial prescribing was issued in February 2020 

https://www.nice.org.uk/guidance/ng152

3. PAIN ASSESSMENT

Use a reliable pain assessment tool – for example the Visual Analogue Scale (VAS) to record severity and frequency of pain and also assess the impact of pain the on patient’s day to day activities

4. DRESSINGS

When considering how to dress wounds, consider the 4 basic principles of the TIME acronym:

Tissue – assess the tissue type and remove any dead tissue in order to encourage the formation of healthy granulation tissue

Inflammation and infection – look for any evidence of infection and treat appropriately

Moisture balance – vital to successfully manage exudate (wound fluid) to maintain a moist wound environment which is essential for optimum healing

Edge – remove any scabs which will be a barrier to the progression of new epidermis across the wound bed This can be done either manually or by using a hydrocolloid dressing or an alternative that donate moisture to the wound bed.

EWMA Statement 5.3.f: simple non-adherent dressings are recommended for the majority of small and non-complicated venous leg ulcers.

However, a suitable dressing is needed to treat a particular problem. If the wound appears infected, an anti-microbial dressing can be used for a maximum of two weeks then review.

If the wound base contains dry slough or necrotic tissue, a dressing that will hydrate the wound and de-slough should be used such as a hydrocolloid or hydrogel. Absorbent or super absorbent dressings should be used if exudate levels are high with frequent dressing change.

The peri-wound skin needs to be protected from maceration with a barrier cream/spray and if dressing is particularly painful, consider silicone dressing for atraumatic removal.

Further Reading:

World Union of Wound Healing Societies (WUWHS). Principles of best practice: Compression in venous leg ulcers. A consensus document. London: MEP Ltd, 2008

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