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 patient’s treatment plan is individualized, based on the patient’s 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
- Synthetic skin substitutes
Arterial Ulcer Treatment
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
How Should I Treat A Leg Infection
The most appropriate treatment for a leg infection depends on the particular type of infection. Some affect a persons skin cells while others may involve the bone or lymph nodes. If a person suspects he has an infected leg, he should see a doctor for a diagnosis and treatment recommendation. Some seemingly minor infections can become severe if left untreated or if theyre treated with the wrong types of medication.
One type of infection that may affect a persons leg is called cellulitis. This infection involves the cells right below the skins surface, causing inflammation in the affected area. It develops when the skin is broken, such as because of a cut, broken blister or animal bite. The broken skin allows bacteria to enter the body, which leads to the infection. There are many types of bacteria that cause cellulitis, but those in the strep family are the most common.
Oral antibiotics are usually used to treat a cellulitis leg infection and usually cure it within a week or so. A patient may return to his doctor after about a week to check whether it has gone away entirely. In a severe case, a person may need to be hospitalized and treated with intravenous antibiotics.
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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
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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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.
Best Cream For Leg Ulcers
Many people suffer from leg ulcers. Leg ulcers are similar to a break in the skin of the leg, which allows air and bacteria to get to the underlying tissues. It can be formed by a minor injury that breaks the skin. It is also caused due to obesity, diabetes, and hypertension.
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What Causes A Leg Ulcer
A venous leg ulcer happens when someone with poor blood circulation suffers a minor injury.
Poor blood circulation in the legs causes the pressure inside the veins to increase. Prolonged high pressure will damage the small blood vessels in the legs, making them very delicate. If the skin is subsequently broken due to even a small knock or scratch, the skin will break, creating a sore. Because of the poor circulation, the sore will take a very long time to heal. A chronic sore on the legs is called a leg ulcer.
As mentioned above, old age significantly increases the risk of a leg ulcer. Other risk factors include:
- History of leg injury e.g. fractured bone
- History of leg surgery e.g. knee replacement
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 silver-based products. Further good quality research is required before definitive conclusions can be drawn about the effectiveness of antibiotic tablets and topical agents such as povidone-iodine, peroxide-based products and other topical antibiotics and antiseptics in healing venous leg ulceration.
Venous leg ulcers are a type of chronic wound affecting up to 1% of adults in developed countries at some point during their lives. Many of these wounds are colonised by bacteria or show signs of clinical infection. The presence of infection may delay ulcer healing. Two main strategies are used to prevent and treat clinical infection in venous leg ulcers: systemic antibiotics and topical antibiotics or antiseptics.
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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 .
Epidemiology And Risk Factors
Pressure ulcers are areas of necrosis caused by compression between bony prominences and external surfaces. The damage may be relatively minor, or it may lead to massive destruction of deeper tissues, which can cause significant morbidity and mortality. The incidence and prevalence of pressure ulcers depends on the definition of pressure ulcers used and the patient population studied. The National Pressure Ulcer Advisory Panel has classified pressure ulcers according to 4 stages :
Stage I: Nonblanchable erythema of intact skin.
Stage II: Partial-thickness skin loss involving the epidermis or dermis lesions may present as an abrasion, blister, or superficial ulcer.
Stage III: Full-thickness skin loss that may extend to, but not through, the fascia the ulcer may be undermined.
Stage IV: Full-thickness skin loss involving deeper structures, such as muscle, bone, or joint structures.
Risk factors for the development of pressure ulcers are either intrinsic or extrinsic. Limited mobility and poor nutrition are the strongest intrinsic predictors of pressure ulcer formation. Incontinence, increased age, diabetes mellitus, stroke, white race, skin abnormalities, and male sex have also been implicated by multivariate analysis in some studies . Extrinsic factors include pressure, friction, shear stress, and moisture of these, the most important is pressure.
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What Causes Wound Infections
Your skin protects your body from various pathogens. A wound is an opportunity for bacteria and other microorganisms to enter your body and cause problems like inflammation and tissue damage. An infection can start in a wound within a couple of days. The risk of infection is present until the wound heals.
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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B Searching For The Evidence: Literature Search Strategies For Identification Of Relevant Studies To Answer The Key Questions
We will search the following databases for primary studies: MEDLINE®, EMBASE®, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature . We will develop a search strategy for MEDLINE, accessed via PubMed®, based on an analysis of medical subject headings and text words of key articles identified a priori. Our search strategy for MEDLINE is presented in Tables 57. The search will be updated during the peer review process.
Additionally, the team will search clinicaltrials.gov to identify relevant registered trials. We will review the Scientific Information Packets provided by the pharmaceutical manufacturers.
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.
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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
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
- R – Red friable
- D – Debris ) in wound
- S – Smell
Presence of Spreading Bacteria
- S – Size increasing
- T – Temperature increased
- O – Os
- 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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Infection Of Venous Leg Ulcers
The most common complication of venous leg ulcers is infection, which can arise from a variety of sources, including the following:1
- Bacterial: furuncles, ecthyma, mycobacterioses, syphilis, erysipelas, anthrax, diphtheria, chronic vegetative pyoderma, tropical ulcer
- Viral: herpes, variola virus infection, cytomegalovirus infection
- Fungal: sporotrichosis, histoplasmosis, blastomycosis, coccidioidomycosis
- Protozoal: leishmaniasis
When infection is present in the VLU, the patient may present with fever, wound fluid rich in leukocytes, increasing pain, cellulitis, necrotic tissue, and purulent exudate with or without odor. When signs of infection are present, the patient should be treated with appropriate systemic antibiotics, topical antimicrobials, or antiseptics.2 However, VLUs that are critically colonized with bacteria or bacterial biofilms without signs of systemic infection may be treated in multiple ways, including topical antibiotics. Sequential, aggressive debridement can also be used to treat infected ulcers.1