A complete guide to leg ulcers ROW

A COMPLETE GUIDE TO LEG ULCERS

– making the right diagnosis and facilitating more rapid healing of troublesome leg ulcers

A COMPLETE GUIDE TO LEG ULCERS

Hard-to-heal leg ulcers can be troublesome, and for the healing process to begin, the right diagnosis needs to be made, with appropriate treatment measures put in place.

This complete guide to leg ulcers will help you to understand various wounds, what distinguishes them, and how they can best be treated during and after the healing process.

IDENTIFYING VARIOUS LEG ULCERS

There are a number of different types of leg ulcers, and it is important for treatment for the diagnosis to be correct. Leg ulcers may be venous or arterial, but there are also diabetic foot ulcers, pressure ulcers or malignant leg ulcers.

VENOUS LEG ULCERS

Venous leg ulcers are the most common type of leg ulcer. The ulcer often develops on the inside of the lower leg, in the area around the ankle, and a characteristic feature is the superficial ulceration. The leg is often swollen as a result of the venous valves not functioning normally, which often causes a heavily exuding wound. The skin around the ulcer may be discoloured and there may be signs of eczema and scaling too.

ARTERIAL ULCERS

Arterial ulcers tend to occur on the foot, but may also develop on the lower leg. An arterial ulcer is often deep and painful for the patient. The wound’s appearance can vary and it will often be dry with black and yellow necrotic tissue. Ulcers are caused by the arterial circulation being interrupted, with surgery being required to restore the circulation. Poor arterial circulation is diagnosed by recording the patient’s blood pressure at the ankle and comparing it with the pressure in their arm. If the pressure is lower at the ankle, a consultation should be arranged with a vascular surgeon.

DIABETIC FOOT ULCERS

Common causes of diabetic foot ulcers are poor peripheral circulation or peripheral nerve damage. A loss of sensation in the feet and toes, for example, can lead to ulcers developing after chafing or pressure from shoes. 15% of adults with diabetes will develop a diabetic foot ulcer at some point in their life.

PRESSURE ULCERS

Pressure ulcers on the legs usually occur in vulnerable areas such as the ankle and heel. Tissue sensitivity to pressure varies, and pressure ulcers can develop under high pressure in a short space of time, or under low pressure over a longer period of time. The pressure causes a lack of oxygen locally and tissue necrosis, which leads to ulceration. In the case of a pressure ulcer, relieving the pressure is an essential aspect of wound care. To avoid pressure ulcers developing, prevention measures (pressure ulcer prophylaxis) are vital.

MALIGNANT LEG ULCERS

Malignant leg ulcers may be considered a type of fungating wound and a wound resulting from tissue in another type of leg ulcer having undergone a malignant transformation.

Venous leg ulcers are caused by venous insufficiency, which means that the venous valves in the legs have been damaged and are not functioning normally.

VENOUS LEG ULCERS AND WHAT CAUSES THEM

Venous ulcers account for more than half of all hard-to-heal leg ulcers, and correct diagnosis with the right treatment is crucial for creating the conditions for healing.

Venous leg ulcers are caused by venous insufficiency, which means that the venous valves in the legs have been damaged and are not functioning normally. The venous valves are designed to help push blood and lymph around the body in a constantly circulating flow. Dysfunctional venous valves mean that a significant portion of fluid remains in the lower limbs, which results in oedema – a visible swelling caused by a build-up of fluid.

Oedema and increased pressure in the lower legs leads to the skin being damaged from the inside and the potential for ulceration. External factors, such as a blow or impact to a lower leg with venous insufficiency, may also cause an exuding wound to develop. The fluid, known as exudate, leaks from the wound and a hard-to-heal, exuding venous ulcer forms.

EXUDATE

Exudate is a natural and vital part of a healthy wound healing process. It keeps the wound moist and contains nutrients, proteins and growth factors that promote healing and help to form new tissue. However, problems can occur when there is an accumulation of excess exudate. The exudate in hard-to-heal wounds contains increased levels of inflammatory molecules, which keep the wound in the inflammation phase and can themselves cause more exudate to be produced.

Heavily exuding wounds are a problem for both patients and healthcare staff. The amount of exudate can sometimes be so great that it is possible to see how the wound is filling up. Exudate can leak through on to sheets and clothing, which requires dressings to be changed regularly. The patient may also experience increased anxiety about leaving their home owing to concerns about leakage or an unpleasant odour. Venous leg ulcers therefore often have a significant impact on the patient’s everyday life, which highlights the importance of clear treatments for both causes and symptoms.

THE HEALING PROCESS

PHASE 1

THE INFLAMMATION PHASE

PHASE 2

THE PROLIFERATION PHASE

PHASE 3

THE MATURATION PHASE

THE HEALING PROCESS IN THREE PHASES

It takes time for a venous leg ulcer to heal, and sometimes several months of treatment are required. A wound follows a healing process comprising a number of phases that are usually defined as the inflammation phase, the proliferation phase and the maturation phase.

THE INFLAMMATION PHASE

The inflammation phase starts at the same time as the wound develops and is the first step in the healing process. The inflammation phase means that the wound is being cleaned; a process that is aided by the body’s white blood cells.

THE PROLIFERATION PHASE

The proliferation phase is when new tissue is formed. The signs of inflam-

mation disappear, the wound takes on a bright red colour and looks healthier as new blood vessels grow at the surface. Small bumps may be formed by the tiny growths that gradually fill the wound. Cells that secrete collagen develop and form new tissue and the wound area shrinks as the wound contracts.

During the proliferation phase, it can happen that growth continues beyond what is needed to fill the wound. This leads to what is called hypergranulation, which is not part of the normal healing process.

THE MATURATION PHASE

The final stage of wound healing is the maturation phase. This can last for more than a year depending on the size and nature of the wound. During this period, the skin’s collagen is strengthened and the bright red scar fades over time.och storlek. Unden den här perioden stärks hudens kollagen och det ljusröda ärret bleknar med tiden.

INFECTED LEG ULCER

Healing can sometimes go wrong at the proliferation phase. If the wound has been open for a long time, it has a reduced ability to fight off bacteria that grow in the wound. The bacteria thrive in moist conditions, and the more exudate and moisture there is in the wound, the more bacteria there will be.

Bacteria are always present on the surface of a wound. Normally, these are bacteria from the body’s own skin and mucosal flora, such as staphylococci,

enterococci and intestinal bacteria, but there may also be other bacteria present. If the bacteria penetrate deeper into the wound, an infection develops. If a wound is infected, the patient experiences more pain, which is observed when cleaning and dressing the wound. Redness, increased discharge from the wound, odour and swelling are other indications that a leg ulcer has become infected. If you suspect an infection, a doctor must assess the need for antibiotic treatment.

TREATMENT OF VENOUS LEG ULCERS

To treat an exuding wound caused by venous insufficiency, it is necessary to treat the underlying cause, and to create the right conditions for the wound to heal. Cleaning the wound thoroughly, using appropriate wound dressings and compression therapy to tackle the swelling provide a good basis for the wound healing process.

CLEANING VENOUS LEG ULCERS

To treat a venous leg ulcer, the wound area needs to be cleaned and looked after. Bacteria are always present in the wound area, but the formation of a biofilm can prevent healing.

It is normal for there to be dried exudate and fibrin present in the wound. Such deposits can be removed through mechanical wound cleaning using a gentle monofilament pad, for example.

If there is devitalised tissue in the wound, this often needs to be removed through debridement, which is the removal of devitalised tissue using a scalpel or scissors. Removing devitalised tissue is a part of the treatment that should be carried out by a doctor or an experienced nurse.

WOUND JOURNAL

Once the wound has been cleaned, the status and development of the wound must be constantly assessed and documented in a wound care diary. Examining the wound edges and measuring the size of the wound provides an indication of whether healing is progressing or not. When dressings are changed, standardised words should be used to describe the wound’s appearance and record it in the wound care diary. The wound edges can, for example, be described as sloping, high, punched-out, macerated, epithelialised or rolled. The appearance of the wound area must be carefully described in order to determine whether the wound has a fibrin coating, is granulating or is necrotic.

Removing devitalised tissue is a part of the treatment that should be carried out by a doctor or an experienced nurse.

COMPRESSION THERAPY

Compression is the mainstay of treatment in cases of wounds caused by venous insufficiency and a compression bandage can sometimes be left untouched for a week. For this reason, a suitable wound dressing is crucial, for example, a superabsorbent dressing with a dressing change frequency matching that of the compression therapy, not the other way round.

The compression bandage is an important treatment measure in cases of a venous leg ulcer. When the leg is bandaged for compression, it makes it easier for venous blood and lymph to leave the leg and be transported back to the heart.

Compression therapy reduces swelling in the lower leg and there is reduced leakage from the exuding wound. Less

exudate makes for an improved wound edge environment and the interval between treatments can be extended.

There are currently a number of compression systems to choose from. Short-, medium- or long-stretch bandages are used depending on the patient’s level of mobility. The manufacturer’s instructions explain how the bandage is to be applied.

Clear guidelines for compression therapy are provided in the guide “Simplifying venous leg ulcer management”. The guide is therefore a good support tool when choosing a compression system with the right compression dose based on the patient’s diagnosis.

WOUND DRESSINGS FOR EXUDING WOUNDS

It is important to choose a suitable dressing that does not need to be changed frequently. The dressing’s capacity to absorb exudate should correspond to the bandage change interval of the compression therapy. An ulcer covered with an effective dressing can remain undisturbed for longer, which also aids healing.

A superabsorbent dressing is designed to work best with exuding wounds because the dressing absorbs and encapsulates the exudate, forming a gel inside the dressing’s core.

The dressing’s excellent absorption capacity means fewer dressing changes, as the surface of the dressing remains dr y. A dry dressing surface also reduces the risk of the surrounding skin becoming macerated.

Superabsorbent dressings that encapsulate the exudate and keep the surface of the dressing dry are the ideal choice for use with compression therapy. The dressings come in various formats and sizes and all have great absorption capacity. This makes it easy for the caregiver to choose a dressing suitable for a particular type and size of wound.

REDUCED LABOUR (HEALTHCARE STAFF)

COSTS WITH SUPERABSORBENT DRESSINGS

Using a superabsorbent dressing that extends the length of time between dressing changes is good for both the patient and healthcare services. The dressing has properties that promote more rapid healing, which spares the patient uncertainty and pain and saves time.

For the caregiver, superabsorbent dressings also have a financial advantage compared with traditional dressings, as fewer changes save healthcare staff time and therefore contribute to reduced labour costs.

CLINICAL USE OF DRYMAX SUPERABSORBENT DRESSINGS

49 % FEWER DRESSING CHANGES

33 % LOWER LABOUR COSTS

20,5 H NURSING TIME SAVED PER AVERAGE WEEK

(Höglin G., Freijd H. 2011)

55 % AVERAGE MATERIAL COSTS SAVED WEEKLY

The study was conducted using wound dressings from DryMax, a brand belonging to Absorbest AB, which operates within the medical device field and specialises in advanced wound care. The DryMax brand includes superabsorbent dressings that simplify wound care in patients with exuding wounds. Absorbest’s production facilities and offices are located in Sweden.

AFTERCARE

Venous leg ulcers should heal with the correct treatment, but there is a considerable risk of recurrent venous leg ulcers. This is because the veins in the leg are still damaged and have not recovered their normal function. Treatment must therefore continue, even after the ulcer has healed, with medical compression hosiery for lifelong follow-up care. Other chronic conditions must also be treated, and there should be particular emphasis on diet, exercise and quitting smoking.

SOURCES

Harding, K., et al. Simplifying venous leg ulcer management, Consensus recommendations. Wounds International, 2015. Available to download from www.woundsinternational.com

Höglin G., Freijd H. A cohort study to investigate the benefit of the use of DryMax Extra superabsorbent wound dressing on a population of wet wounds, 2011; Poster presentation, Harrogate.

Lindholm C., MD, professor, Sophiahemmet University, Stockholm,

2018, www.vardhandboken.se (Downloaded 02-2020)

Lindholm C. Sår. [Wounds] Ed. 4:2 Studentlitteratur AB, 2018

Nyström P-O.; Chief surgeon, retired associate professor [Expert comment]

World Union of Wound Healing Societies (WUWHS). Consensus Document. Wound Exudate - Effective assessment and management. Wounds International, 2019