Identification and recommended management of leg ulcers Jill Robson RGN and Gerard Stansby MA, MChir, FRCS thickened skin, lipodermatosclerosis skin stained haemosiderin shallow ulcer irregular shape Our series Prescribing in older people gives practical advice for successful management of the special problems faced by this age group. Here, the authors describe how to recognise and treat leg ulcers. distended foot vessels Figure 1. Venous leg ulcer illustrating some typical features Leg ulcers are common and will affect 1 per cent of the population, the incidence rising age. The negative impact on quality of life and the cost to the health service are considerable. Treatment depends upon identification and management of the underlying pathology, prevention of recurrence after the ulcer has healed. Community nurses see most patients at home but, as this service is for housebound patients, practice nurses often see those who can get to the surgery. In some areas nurses have set up leg ulcer clinics for patients from a number of practices. There are also some patientled Leg Clubs. Wherever the patient is seen, they should be assessed and treated by a healthcare professional who has had appropriate training. Training courses are available through university nursing departments, from pharmaceutical companies or delivered locally by specialist nurses. Referral to hospital may be required to clarify aetiology, or for surgical correction of arterial or venous vascular. Aetiology Most ulcers at the ankle are due to venous (see Figure 1 and Table 1). Chronic venous hypertension leads to congestion at the capillary bed venous blood. The surrounding tissues are then deprived of oxygen and become damaged. Blood can leak from the distended capillaries and form a cuff of fibrin around the capillary wall, further preventing the passage of oxygen and nutrients to the skin. Added to this, white blood cells become activated in response to the damage, and these activated www.prescriber.co.uk Prescriber 5 May 2009 55
cells are trapped in the area causing further damage. Ulcers that are due to chronic venous hypertension will respond to compression bandaging. It is, however, vitally important to identify patients arterial, or mixed arterial and venous, for whom compression can be dangerous. Assessment A trained practitioner should assess the patient prior to treatment the aim of deciding upon aetiology. Assessment includes history (see Table 2), physical examination (see Table 3) and measurement of the ankle to brachial pressure index (ABPI, see Figure 2). Ankle to brachial pressure index The ABPI can identify patients who appear to have venous but whose underlying arterial is not evident. The test should be performed and interpreted by a trained practitioner as part of the assessment for all leg ulcer patients. It compares the blood pressure in the leg arteries that in the brachial artery, using Doppler ultrasound to detect flow and a sphygmomanometer to measure the pressure. Division of the highest pressure at which Doppler pulsation was detected in the ankle by the highest pressure in the brachial artery produces a value for the ABPI. Patients calcified or sclerotic arterial walls (often patients diabetes) may have falsely high readings as the sphygmomanometer cuff cannot occlude the artery, so the ABPI can only be interpreted alongside the other clinical findings. Other causes of ankle ulceration These are rare, but include malignancy, pyoderma gangrenosum, venous around 60-70% arterial around 10-15% mixed venous/arterial around 10-15% other around 5% Table 1. Causes of leg ulcers History suggesting venous previous deep vein thrombosis varicose veins phlebitis raised intra-abdominal pressure previous fractures/orthopaedic surgery (increased risk of silent DVT) occupation involving long periods of standing fixed ankle joint (poor calf muscle pump) family history History suggesting arterial smoking high cholesterol hypertension diabetes age arterial elsewhere angina myocardial infarction cerebrovascular accident transient ischaemic attacks peripheral vascular family history Table 2. History suggesting venous and arterial autoimmune s, diabetic vasculitis, diabetic neuropathy, lymphoedema, and tropical and factitious ulcers. Taking a careful medical history will help to identify patients these conditions. It is worth considering a rarer cause if a patient fails to respond to optimum treatment. If any of these causes is suspected, then referral should be made to the appropriate specialist service as further investigations, including biopsy, may be required. Prescribing compression therapy It is important to take into consideration the preference and training of the nurses treating the patient, the size of the patient s leg and the patient s lifestyle and mobility. Once the oedema has reduced and the ulcer is under control, most systems can be left in place for up to one week. When the patient s ulcer is of a venous aetiology, a compression kit should be chosen that would give 35-40mmHg at the ankle, graduating to half that under the knee. If there is some question as to skin perfusion a compression bandage, such as an ABPI of between 0.6 and 0.8, or clinical signs of poor arterial perfusion, then reduced compression can be used, but caution and by an experienced practitioner. Patients who have an arterial ulcer should not be treated compression. 56 Prescriber 5 May 2009 www.prescriber.co.uk
Skin care The patient s leg and foot should be washed in warm tap water to remove debris and odour. An unperfumed simple emollient can be applied at the same time. The troublesome itching associated varicose eczema can be treated a mild steroid ointment. Varicose eczema is a result of chronic venous insufficiency and should also be treated compression. Primary dressings A simple nonadherent wound contact layer is sufficient. Avoid bulky dressings as they alter the compression profile of the bandages. Antimicrobial dressings can be used for short periods to reduce the bacterial burden on the surface. Elastic compression Compression of 35-40mmHg at the ankle, graduating to 17-20mmHg under the knee, is required to reverse chronic venous hypertension. To achieve the optimum compression, large limbs require a bandage more power, small limbs require a bandage less power. Multilayer systems This is the gold standard for venous leg ulcer treatment. Many kits are available on prescription for the average-sized limb (ankle circumference 18-25cm). However, if the patient s limb is not this size, the bandage will not provide the correct amount of compression. An appropriate kit should be prescribed from the Profore or ProGuide ranges. There is a kit for patients average-sized limbs who require less compression (Profore Lite), and latex-free kits are also available. Appropriately trained nurses should apply compression. Signs and symptoms of venous Varicose eczema Varicose veins Pain when the leg is dependent, relieved by elevation Champagne bottle leg; loss of muscle bulk in the lower part of the leg oedema collecting above it Lipodermatosclerosis woody scaly skin; hardening of the dermis and the subcutaneous fat Haemosiderin staining; brown discoloration in the skin from the breakdown of red blood cells having leaked from distended capillaries Oedema accompanied by 1 or more other symptoms (take care that it is not due to congestive cardiac failure) Telangiectasia, or ankle flare; a crop of distended vessels in the skin of the foot and ankle Atrophie blanche; white patches of scarred-looking skin, dotted distended red capillary loops Appearance of the ulcer; venous ulcers are shallow and have an irregular shape Location above the level of the malleolus on the lower third of the calf Signs and symptoms of arterial Pain when the limb is elevated, sometimes known as rest pain; worse at night; patients often hang the limb out of the bed, or sleep in a chair Intermittent claudication; cramp-like calf, thigh or buttock pain that comes on during exercise and stops after a few minutes rest Loss of colour on elevation; may be associated dependent rubor or atrophic shiny skin (Buerger s test) Location of the ulcer; ulcers on the toes or foot Appearance of the ulcer; deeper, a punched-out edge often sloughy or necrotic tissue Absent pulses Poor capillary return Low ABPI Evidence of arterial in opposite leg Table 3. Signs and symptoms of venous and arterial ABPI = 0.8-1.2 picture of venous venous ulcer mixed ulcer arterial ulcer Figure 2. Interpretation of ABPI results APBI = 0.6-0.8 picture of venous and some features of arterial ABPI = <0.6 picture of arterial www.prescriber.co.uk Prescriber 5 May 2009 57
Assessment by trained practitioner to include: history physical examination examination of ulcer and surrounding skin ABPI pain mobility nutritional state BP urinalysis venous insufficiency mixed venous and arterial arterial insufficiency treat compression bandage by trained practitioner advise exercise and elevation consider vascular referral for venous surgery consider reduced compression or take advice from experienced practitioner, eg tissue viability nurse (TVN) possible referral to vascular service for intervention pain relief consider urgent referral to vascular surgeon pain relief good local wound care take advice from experienced practitioner, eg TVN do not bandage Healed fit compression hosiery of at least 18-24mmHg consider referral for venous surgery Not healed at 24 weeks reassess and treat symptoms Healed fit compression hosiery of up to 18-24mmHg monitor skin perfusion closely other cause refer to appropriate specialist service follow up according to specialist advice Figure 3. Recommended management of venous, arterial and mixed ulcers British classification Class 1 (light support) provides 14-17mmHg at the ankle, suitable for superficial early varicosities Class 2 (medium support) provides 18-24 mmhg at the ankle, suitable for medium varicosities, mild oedema and prevention of ulceration Class 3 (strong support) provides 25-35mmHg at the ankle, suitable for gross varicosities, gross oedema and prevention of ulcer recurrence Continental classification Class 1 provides 18-22mmHg at the ankle; for mild varicosities and swollen aching legs Class 2 provides 23-33mmHg at the ankle; for prevention of ulcer recurrence, severe varicosities and chronic venous insufficiency Class 3 provides 34-46mmHg at the ankle; for severe chronic venous insufficiency, post-thrombotic limb and reversible lymphoedema Table 4. British and Continental classification systems Inelastic short stretch bandages These bandages provide a rigid casing around the leg; when the muscle is activated, the pressure on the deep veins increases, improving venous return. They will be most effective if the patient is relatively mobile. Some can be washed and reused. Attenuated-stretch systems These combine the effects of elastic and inelastic bandages and may address problems such as slippage. Stocking kits If the ulcer is small and has minimal exudate and the leg is a nor- 58 Prescriber 5 May 2009 www.prescriber.co.uk
Resources Further reading The management of patients venous leg ulcers. Royal College of Nursing Clinical Practice Guidelines. RCN Institute, 2006. The care of patients chronic leg ulcers. Scottish Intercollegiate Guideline Network. SIGN Secretariat, 1998. Compression therapy: a guide to safe practice. Marston W, et al. In: Understanding compression therapy (EWMA position document). MEP, 2003. Protocol for the accurate measurement of ABPI in patients leg ulcers. Stubbings NJ, et al. J Wound Care 1997;6:417-8. Compression therapy in venous leg ulcers. How does it work? Partsch H. J Phlebol 2002;2:129-36. A colour guide to the assessment and management of leg ulcers. Morrison M, et al. 2nd ed. London: Mosby, 1994. Websites www.legulcerforum.org. www.worldwidewounds.com. www.woundsuk.com. mal shape, a stocking kit designed to provide up to 40mmHg at the ankle can be used. Preventing recurrence Venous ulcers often recur if the underlying chronic venous insufficiency is not corrected. Some patients may benefit from varicose vein surgery and should be referred for venous Duplex assessment. The majority should be fitted for belowknee compression hosiery (see Table 4), class 3 (British classification) or class 2 (Continental classification). It is worth noting that the two classification systems are different and are not interchangeable. The patient s skin condition and perfusion should be checked, and the leg re-measured whenever the hosiery prescription is renewed. Conclusion Successful management of leg ulcers depends upon clinical judgment and diagnostic skills, combined expertise in the application of effective therapy. Care will need to continue throughout the patient s life. Healthcare professionals caring for this patient group should have appropriate training. Jill Robson is vascular nurse specialist and Gerard Stansby is professor of vascular surgery in the Northern Vascular Unit, Freeman Hospital, Newcastle-upon-Tyne