Prevention Of Ulcer Recurrence
Factors that are associated with ulcer nonhealing and recurrence: Overweight body mass index, history of deep venous thrombosis, large ulcer area, noncompliance with compression therapy, and triple-system venous disease involving superficial, perforating, and deep veins . The strategies to prevent the ulcer recurrence should target these factors. These could be implemented as regular clinical evaluations, patient education and life-long compression therapies. Patientâs education should be regarding skin care, elevation of the affected limb when immobile, compliance to compression therapy, encourage mobility, and exercise. To encourage, early self-referral at signs of possible skin breach.
Use of compression stockings reduces ulcer recurrence and is thus highly recommended in patients of venous leg ulcers. Patients are encouraged to wear the strongest compression they can tolerate for life-long, if not contraindicated otherwise .
How Should We Define Wound Infection
Virtually all open wounds are colonized with microorganisms, but this usually has no clinical consequences, because they show no evidence of infection and heal as expected . Some wounds are clearly infected they have purulent secretions or some of the cardinal manifestations of inflammation that have classically defined the host response to tissue damage caused by pathogenic and invasive microorganisms . The likelihood that a wound will become infected is related directly to the inoculum size and virulence of the colonizing organisms and inversely related to local and systemic host resistance . But some wounds occur in patients with neuropathy , ischemia , or venous insufficiency . Because these conditions limit the expression of inflammation, some define infection by secondary signs of local infection, . A Delphi approach by an international group of 54 wound care experts produced consensus on criteria they deemed common to infection in all chronic wounds: cellulitis, malodor, pain, delayed healing, deterioration or breakdown, and increased exudate . Some of these criteria have purportedly been validated by studies of various wounds in several settings, but the findings are limited by the fact that they compare the clinical criteria to inadequately validated microbiological definitions of infection . Furthermore, the additional evidence of infection likely varies for different types of chronic wounds .
Cleaning And Dressing The Ulcer
The first step is to remove any debris or dead tissue from the ulcer and apply an appropriate dressing. This provides the best conditions for the ulcer to heal.
A simple non-sticky dressing will be used to dress your ulcer. This usually needs to be changed once a week.
Many people find they can manage cleaning and dressing their own ulcer under the supervision of a nurse.
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Complications Of Venous Leg Ulcers
Venous leg ulcers are difficult to treat, and when they are present a variety of complications may arise. These complications can be challenging to treat and may often contribute to the prolonged healing times resulting from chronicity found with many VLUs. Further, if the condition of the ulcer deteriorates, it may worsen any complication already present or serve as the catalyst for the development of complications.
C Data Abstraction And Data Management
Two independent reviewers will conduct title scans. For a title to be eliminated at this level, both reviewers will need to indicate that the study was ineligible. If the reviewers disagree, the article will be advanced to the next level, which is abstract review.
The abstract review phase will be designed to identify studies reporting the effects of treatment options for chronic venous leg ulcers. Abstracts will be reviewed independently by two investigators and will be excluded if both investigators agree that the article meets one or more of the exclusion criteria . Differences between investigators regarding the inclusion or exclusion of abstracts will be tracked and resolved through consensus adjudication.
Articles promoted on the basis of the abstract review will undergo another independent parallel review to determine if they should be included in the final qualitative and quantitative systematic review and meta-analysis. The differences regarding article inclusion will be tracked and resolved through consensus adjudication.
We will use a systematic approach to extract all data to minimize the risk of bias in this process. We will create standardized forms for data extraction, which will be pilot tested. By creating standardized forms for data extraction, we seek to maximize consistency in identifying all pertinent data available for synthesis.
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Antibiotics And Antiseptics To Help Healing Venous Leg Ulcers
Venous leg ulcers are a type of wound that can take a long time to heal. These ulcers can become infected, and this might cause further delay to healing. Two types of treatment are available to treat infection: systemic antibiotics and topical preparations . Whether systemic or topical preparations are used, patients will also usually have a wound dressing and bandage over the wound. This review was undertaken to find out whether using antibiotics and antiseptics works better than usual care in healing venous leg ulcers, and if so, to find out which antibiotic and antiseptic preparations are better than others. In terms of topical preparations, some evidence is available to support the use of cadexomer iodine . Current evidence does not support the use of honey or silverbased products. Further good quality research is required before definitive conclusions can be drawn about the effectiveness of antibiotic tablets and topical agents such as povidoneiodine, peroxidebased products and other topical antibiotics and antiseptics in healing venous leg ulceration.
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How Are Leg Ulcers Treated
At Cleveland Clinic, patients are treated by a team of world-class experts in the Lower Extremity Wound Clinic in the Department of Vascular Medicine. This Clinic includes doctors, nurses and other medical specialists.
These experts work together to determine the cause of the ulcer and develop an individualized treatment program.
The goals of treatment are to relieve pain, speed recovery and heal the wound. Each patients treatment plan is individualized, based on the patients health, medical condition and ability to care for the wound.
Treatment options for all ulcers may include:
- Antibiotics, if an infection is present
- Anti-platelet or anti-clotting medications to prevent a blood clot
- Topical wound care therapies
- Prosthetics or orthotics, available to restore or enhance normal lifestyle function
Venous Ulcer Treatment
Venous ulcers are treated with compression of the leg to minimize edema or swelling. Compression treatments include wearing compression stockings, multi-layer compression wraps, or wrapping an ACE bandage or dressing from the toes or foot to the area below the knee. The type of compression treatment prescribed is determined by the physician, based on the characteristics of the ulcer base and amount of drainage from the ulcer.
The type of dressing prescribed for ulcers is determined by the type of ulcer and the appearance at the base of the ulcer. Types of dressings include:
- Moist to moist dressings
Arterial Ulcer Treatment
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Venous Leg Ulcers And Infection
The venous leg ulcer is the most common type of chronic leg wound, and it can be challenging to manage.1 VLUs account for up to 90% of all chronic leg ulcers.1 Proper diagnosis and treatment planning are key to wound healing outcomes. This fact is particularly true for older adults, who have an annual VLU prevalence of 1.7%.2
Signs And Symptoms Of Wound Infection12
RNAO Evidence Levels:
Venous ulcers, like most chronic wounds, can become infected with superficial or spreading bacteria. The validated mnemonics NERDS and STONEES classify the signs and symptoms of localized infection and spreading infection . Increased localized pain is a significant predictor of deep compartment infection.
Presence of Superficial Bacteria
- N New areas of breakdown
- E Exudate present
- E Erythema and/or Edema
- S Smell
In addition to recognizing the signs and symptoms of infection in venous leg ulcers, it may be helpful to obtain a culture and sensitivity using a validated method of sampling to quantify bacteria in wounds. Tissue biopsies are considered the gold standard but unfortunately are not practical in many settings. Fortunately, a linear relationship between quantitative tissue biopsy and swab for C& S taken using the Levine method of sampling has been validated and is recommended for assessing any open wound. Swabs for C& S are important in determining the type of bacteria and the appropriate antibiotics, but are not necessary to confirm the presence or absence of infection. The C& S results may not reflect the presence or absence of biofilm.
Levine Method for obtaining C& S laboratory swab
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Can Leg Ulcers Be Prevented
To prevent and promote healing of ulcers:
- Avoid injury, particularly when pushing a supermarket trolley. Consider protective shin splints.
- Walk and exercise for at least an hour a day to keep the calf muscle pump working properly.
- Lose weight if you are overweight.
- Stop smoking.
- Check your feet and legs regularly. Look for cracks, sores or changes in colour. Moisturise after bathing.
- Wear comfortable well-fitting shoes and socks. Avoid socks with a tight garter or cuff. Check the inside of shoes for small stones or rough patches before you put them on.
- If you have to stand for more than a few minutes, try to vary your stance as much as possible.
- When sitting, wriggle your toes, move your feet up and down and take frequent walks.
- Avoid sitting with your legs crossed. Put your feet up on a padded stool to reduce swelling.
- Avoid extremes of temperature such as hot baths or sitting close to a heater. Keep cold feet warm with socks and slippers.
- Consult a chiropodist or podiatrist to remove a callus or hard skin.
- Wear at least Grade 2 support stockings if your doctor has advised these. This is particularly important for the post-thrombotic syndrome, leg swelling or discomfort, and for long-distance flights.
- Have a vascular ultrasound assessment and consult a vascular surgeon to determine whether any vein treatment should be carried out.
- Horse chestnut extract appears to be of benefit for at least some patients with venous disease.
Cleveland Clinic Heart Vascular & Thoracic Institute Vascular Medicine Specialists And Surgeons
Choosing a doctor to treat your vascular disease depends on where you are in your diagnosis and treatment. The following Heart, Vascular & Thoracic Institute Sections and Departments treat patients with all types of vascular disease, including blood clotting disorders:
Section of Vascular Medicine: for evaluation, medical management or interventional procedures to treat vascular disease. In addition, the Non-Invasive Laboratory includes state-of-the art computerized imaging equipment to assist in diagnosing vascular disease, without added discomfort to the patient. Call Vascular Medicine Appointments, toll-free 800-223-2273, extension 44420 or request an appointment online.
Department of Vascular Surgery: surgery evaluation for surgical treatment of vascular disease, including aorta, peripheral artery, and venous disease. Call Vascular Surgery Appointments, toll-free 800-223-2273, extension 44508 or request an appointment online.
You may also use our MyConsult second opinion consultation using the Internet.
The Heart, Vascular & Thoracic Institute also has specialized centers and clinics to treat certain populations of patients:
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F Grading The Evidence For Each Key Question
At the completion of our review, at least two reviewers will independently assign evidence grades. Conflicts will be resolved through consensus or third-party adjudication. We will grade the strength of evidence based on the quantity, quality, and consistency of the best available evidence, addressing KQs 1, 2, and 3 by adapting an evidence grading scheme recommended in the Methods Guide.13 We will apply evidence grades to the bodies of evidence about each intervention comparison for each outcome. We will assess the risk of bias of individual studies according to study design characteristics, such as confounding and selection and information biases. We will assess the strength of the best available evidence by assessing the limitations to individual study quality , consistency, directness, precision, publication bias, and the magnitude of the effect.
We will classify evidence pertaining to the KQs into four basic categories: 1) high grade 2) moderate grade 3) low grade and 4) insufficient grade .
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What You Need To Know
The cornerstone of treatment for venous leg ulcers is compression therapy, but dressings can aid with symptom control and optimise the local wound environment, promoting healing
There is no evidence to support the superiority of one dressing type over another when applied under appropriate multilayer compression bandaging
When selecting a dressing, look at the wound bed, edge and surrounding skin and decide on the goal of the dressing: for example, if there are signs of localised infection consider an antimicrobial dressing, if there is heavy exudate consider an absorbent dressing
A 65 year old man presents with a two month history of a wound in the gaiter area of his left leg. He has a history of a left leg deep vein thrombosis after a long flight but is otherwise fit and well. He had been self-managing with dressings bought over the counter, but the wound has gradually increased in size. The wound is not painful but is weeping serous fluid, causing irritation of the surrounding skin. Examination shows a 4×3×0.1cm wound above the left medial malleolus. There is haemosiderin deposition, venous flare, and moderate oedema in the limb. The ankle-brachial pressure index is normal at 1.0. He is diagnosed with a venous leg ulcer, which is managed with dressings and compression bandaging.
About 1% of the adult population in Westernised countries are affected by venous ulcers on the leg or foot.2 The prevalence increases with age to 1.7% in
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Data Collection And Analysis
Information on the characteristics of participants, interventions and outcomes were recorded on a standardised data extraction form. In addition, aspects of trial methods were extracted, including randomisation, allocation concealment, blinding of participants and outcome assessors, incomplete outcome data and study group comparability at baseline. Data extraction and validity assessment were conducted by one author and checked by a second.
Topical Antimicrobials And Antiseptics
Antibiotics are indicated in cases of overt wound infection where the classical signs of infection are evident .
In chronic wounds, reduction of certain microbial species, such as anaerobic bacteria in order to limit undesirable odors or perhaps mixed communities of four or more bacterial species that impede healing use of topical antibiotics may be justified .
Various studies on dressings incorporating antibiotics and antiseptics are reviewed, but no single consensus for any particular topical agent could be made. This is partly due to the different mechanism and spectrum of action of the antimicrobials. The most frequently used topical antimicrobials in wound care practice are chlorhexidine, iodine, silver containing products, and mupriocin, fucidic acid. In the past acetic acid, honey, hydrogen peroxide, sodium hypochlorite, potassium permanganate, and proflavine have been used.
Effective in reducing vascular and epidural catheter bacterial colonization .
Use is associated with fewer adverse effects on wound healing .
Iodine: Available as povidine-iodine and second generation dextranomer and cadexomer
Reduces bacterial load, decreases infection rates and promotes healing .
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Referral To A Specialist
In some cases, your GP or nurse may decide to refer you to a specialist in conditions affecting the blood vessels .
For example, you may be referred to a vascular specialist if your GP or nurse is unsure about your diagnosis, or if they suspect your ulcer may be caused by artery diseases, diabetes or rheumatoid arthritis.
After taking your medical history and examining you, the vascular specialist may need to arrange further investigations to plan your treatment.
Iodine And Silver Preparations:
Several new formulations of older topical agents should be considered to treat nonhealing wounds with or without evidence of clinical infection . Iodine, while toxic in high concentrations to tissue in vitro, can be beneficial at low doses. Cadexomer iodine releases low levels slowly into wounds and has been shown to be safe and effective at decreasing bacterial burden in the superficial compartment. Cadexomer iodine is available as an ointment and as an impregnated gauze dressing.
Silver preparations have been used on ulcers for many years. Nanocrystalline silver can deliver topical concentrations to the superficial compartment that are effective against a range of organisms, including yeast., Use of iodine and silver-containing preparations is summarized in .
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Antibiotics For Wound Infection
Jennifer is a contributing health writer who has been researching and writing health content with PlushCare for 3 years. She is passionate about bringing accessible healthcare and mental health services to people everywhere.
Dr. Katalin Karolyi
Dr. Katalin Karolyi
Katalin Karolyi, M.D. earned her medical degree at the University of Debrecen. After completing her residency program in pathology at the Kenezy Hospital, she obtained a postdoctoral position at Sanford Burnham Prebys Medical Discovery Institute, Orlando, Florida.
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Treating An Infected Ulcer
An ulcer sometimes produces a large amount of discharge and becomes more painful. There may also be redness around the ulcer.
These symptoms and feeling unwell are signs of infection.
If your ulcer becomes infected, it should be cleaned and dressed as usual.
You should also elevate your leg most of the time. Youll be prescribed a 7-day course of antibiotics.
The aim of antibiotic treatment is to clear the infection. But antibiotics do not heal ulcers and should only be used in short courses to treat infected ulcers.
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Venous Leg Ulcer Complications
Osteomyelitis and Septicemia If infection is left unchecked, there is a risk that it will progress to osteomyelitis or even septicemia, which generally require intravenous antibiotics. Extreme cases may require amputation.
Cellulitis Cellulitis is inflammation and infection of the skin, subcutaneous tissue, and lymphatic fluid of the skin1 that causes the area around it to be red, warm, painful, and tender to the touch. It is caused by a type of bacterial infection, generally streptococcal or staphylococcal, but it may be caused by other bacteria as well. It is generally a well-demarcated area . It may cause deterioration of the ulcer and is typically treated with oral antibiotics.3
How much do you know about venous leg ulcer management? Take our 11-question quiz to find out!
Venous Eczema Venous eczema can be a precursor to an ulcer, and it can also persist in varying degrees of severity while an ulcer is present. Eczema found in a VLU can be gravitational eczema, stasis eczema, varicose eczema, or venous eczema, depending on its relationship with the underlying cause. It can also be acute or chronic.4