Venous Insufficiency Ulcers Patient Assessment: Superficial varicosities Evidence of healed ulcers Dermatitis Normal ABI Edema Eczematous skin changes 1. Scaling 2. Pruritus 3. Erythema 4. Vesicles Lipodermatosclerosis Wound characteristics 1. Induration related to fibrotic changes of the dermal and subcutaneous tissues 2. Erythema related to inflammation 3. Hyperpigmentation (hemosiderin deposits) 4. Bony ankylosis of the ankle related to immobility Irregular wound margins Superficial-to-deep wounds Ruddy granular tissue Minimal to moderate aching pain at the borders and middle of the wound bed
Frequent, moderate to heavy exudates Anatomic location frequently at the medial distal lower extremity and ankle, at the malleolar level Differential Diagnosis and possible associated diseases Deep vein thrombosis Extrinsic compression (tumors) Deep vein valve insufficiency Cellulitis Lymphangitis Lymphatic obstruction Wound infection Acute contact dermatitis Superficial venous insufficiency (varicosities) Atrophie blanche, a scar of the lower leg or legs Clinical diagnosis Treatment Depressed atrophic plaques that are polyangular and ivory-white Red dots within the scar related to enlarged capillary blood vessels Surrounding pigmentation Color duplex Doppler (supine and erect) to map out perforating veins and To look at the deep system for reflux and obstruction The first line of venous leg ulcer patients is compression
Elastic (long stretch) bandages Sustain pressure for up to a week Best used in a multi-component system (elastic or inelastic crepe bandage followed by elastic compression bandages) Beneficial for patients who ambulate or have reduced mobility Apply extra padding if the ulcer is over a boney prominence Inelastic (short stretch) bandages Consider using if there is pressure damage from the elastic bandages Requires that the patient be ambulatory for the calf muscle for the calf muscle to press against the bandage to achieve compression Intermittent pneumatic compression is beneficial in patients who Have contraindications for hosiery or bandaging due to peripheral arterial Disease Find bandaging too painful Have a reduced calf muscle functioning (related to limited or no ankle mobility) Have problems with edema control Have pressure damage related to bandages Non-compression treatment options Debride moderate to large amounts of fibrotic tissue to viable tissue Skin substitutes Pentoxifyline along with compression
Elevation of the extremity when not ambulating Vascular consult for treatment to occlude perforators If infected, use Silver Cadexomer Iodine Notes: Compression-induced ulcers can be caused by over-tight bandaging or arterial insufficiency Treatment: Relative contraindication to compression therapy (use with extreme caution) Severe arterial insufficiency Hypodermitis in the acute phase Untreated septic phlebitis of the leg Pulmonary edema Active DVT Uncontrolled or severe congestive heart failure History of CHF or cardiomyopathy
Lymphatic Obstruction/ Lymphedema Assessment: Edema is soft, progressing to spongy and firm Distributed diffusely, more distal then proximal May have massive swelling Mild relief with elevation Bilateral edema is common No pain Feeling of heaviness related to edema Skin is thickened and ulcers are rare Chronic non-healing wound Clear drainage if breaks in the skin Note: While lymphedema is not typically a cause of ulceration unless there is a break in the skin, extremity wounds may fail to heal because of the untreated lymphedema Differential Diagnosis: Veno-lymphatic disease (secondary to congestive heart failure, Hepatic failure, renal failure, other fluid overload states) Primary lymphatic insufficiency Lymphangiosarcoma
Diagnosis: Treatment: History and physical Nuclear lymphangiography Cleanse the skin regularly and dry regularly Dressings: Alginate Foam Silicone Antimicrobials if infected Long-term prophylactic antimicrobial treatment in patients with recurrent lymphangitis or cellulitis Encourage patient weight reduction Patients use compression garments continuously during the day Encourage elevation of the affected extremity when possible and in bed Intermittent pneumatic-pump compression therapy Manual lymphatic drainage Refer to physical therapist with expertise in treating lymphedema Use decongestive physiotherapy for non-responsive lymphedema. Contraindications for pneumatic-pump compression therapy and manual lymphatic drainage include congestive heart failure, deep venous thrombosis, and active infection.
Differential Diagnosis: Edema related to lipedema (a disorder of adipose tissue) Edema is non-pitting Distributed from the waist to the ankles (feet non-affected) Rarely painful Bilateral lower extremity pattern No changes in the skin Edema related to cardiac/ hepatic/ renal insufficiency Edema is pitting Distributed bilaterally, greatest distally May appear over the back if recumbent Relief with elevation Pain usually varies, usually none Skin is shiny, no trophic Hx of cardiac/renal/hepatic insufficiency Peripheral edema related to drugs: Hormones Corticosteroids Estrogen Anti-inflammatory drugs Monoamine oxidase inhibitors Multiple infused drugs and antibiotics with high sodium content