Clinical Pearls & Morning Reports
General principles of management of lower-extremity ulcers include wound débridement, infection control, application of dressings, off-loading of localized pressure, and treatment of underlying conditions such as diabetes mellitus and peripheral arterial disease. Lifestyle changes (e.g., smoking cessation and dietary modifications) should also be made to help manage underlying diseases. Read the latest NEJM Review Article.
Q: What are some of the typical features of venous and arterial lower-extremity ulcers?
A: Venous leg ulcers typically occur over the medial aspect of the lower leg between the lower calf and the medial malleolus (the gaiter area) and are associated with edema, pigment deposition (combined hemosiderin and melanin), venous dermatitis, atrophie blanche (porcelain white scars), and lipodermatosclerosis. Venous leg ulcers are shallow and irregularly shaped and contain granulation tissue or yellow fibrin. Arterial ulcers are often dry and appear “punched out,” with well-demarcated edges and a pale, nongranulating necrotic base. Arterial ulcers may also be very deep.
Q: Is there evidence to support the routine use of prophylactic systemic antibiotics for lower-extremity ulcers?
A: A systematic review of 45 randomized, controlled trials involving a total of 4486 patients showed no evidence that supported the routine use of prophylactic systemic antibiotics for lower-extremity ulcers. Although the review did show evidence that supported the topical use of cadexomer iodine, no evidence supported the prolonged or routine use of silver-based or honey-based products.
A: Wound dressings that promote an appropriate level of moisture (while limiting maceration) and protect the ulcer from further injury and shear stress should be used. A large number of wound dressings are available, including hydrocolloids, alginates, and foams. Many advanced dressings may be left in place for up to a week unless they are malodorous or saturated with exudate. The decision of which dressing to use should be based on the preferences of the patient and practitioner. In general, dry wounds should be treated with moisture-promoting dressings, whereas exudative wounds should be managed with absorptive dressings. Dressings are also available in combination with antiseptic agents (e.g., nanoparticles of silver); these may be helpful in the short term to reduce the concentration of bacteria when infection is present, but they are not recommended for long-term use. Foam dressings, despite their frequent use, are no more effective than other standard dressings.
A: Compression therapy is strongly recommended for venous leg ulcers. The compression dressing is applied from the toes to the knees and should include the heel. Graded pressure is applied, with more pressure applied distally. Each successive wrap should overlap the previous one by 50%. Several large clinical trials and systematic reviews have concluded that compression therapy, as compared with no compression, promotes the healing of venous leg ulcers and reduces the risk of recurrence and is similar to surgical intervention. Multicomponent systems that contain an elastic bandage appear to be more effective than those that have only inelastic components. The recommended compression pressures for the treatment of venous leg ulcers with varicose veins, the postthrombotic syndrome, or lymphedema are between 30 and 40 mm Hg. In the authors’ practices, compression therapy is modified in patients with mild-to-moderate arterial disease (e.g., an ankle–brachial index [ABI] between 0.5 and 0.8) by using inelastic wraps or by reducing the number of layers of compression; the patient is followed closely to ensure that arterial flow is adequate. In severe cases (ABI <0.5), compression should not be used because it may further reduce arterial flow.