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Case Note

Case Note: Non-healing Ulceration on the Leg

History

A 76-year-old healthy male, with a past medical history notable for chronic venous insufficiency, mild diabetes mellitus, hypertension and lower back pain, presents for management of non-healing ulceration on the lower leg.

Initial evaluation

  • Healthy-appearing male
  • Past medical history of:
    • Chronic venous insufficiency
    • Mild diabetes mellitus
    • Hypertension
    • Lower back pain
  • Review of systems non-contributory
  • Presents for management of 7 weeks' history of non-healing ulceration on the lower leg
    • Bilateral lower extremity edema, varicose veins and vascular blebs, brawny hyperpigmentation and xerotic changes, with a 1.4 x 2.6 cm ulceration overlying the left medial malleolus
    • Wound care with a small bandage overlying only
  • No evidence of superinfection
  • Normal sensory and motor testing of the legs
  • Strong, symmetric pedal pulses
  • Patient does not use compression socks
  • Image 1
    Image 1

Enter your diagnosis

Diagnosis

  • A diagnosis of venous stasis ulceration is rendered

Initial Treatment

  • Recommendations:
    • Weekly wound-care changes in the clinic
      • Ulceration measured, then cleansed with dilute soap and water wash
      • Wound dressed with petrolatum ointment, non-stick bandage gauze, Unna bandaging and elastic bandage as the final wrap. Patient instructed that this bandage is to be changed once-weekly in the clinic only
    • Compression stocking prescribed for use on the other leg
  • Follow-up in 7 days

Follow-up evaluation strategy

7-day follow-up evaluation:

  • Ulceration is measured (1.2 x 2 cm) and then cleansed with dilute soap and water wash
  • No evidence of superinfection
  • Area of venous stasis dermatitis surrounding the ulcer appears much improved
  • Wound dressing reapplied
  • Follow up in 7 days
    • Patient required 8 weeks of weekly bandage changes for full re-epithelialization of the leg ulcer

 Further recommendations:

  • For exudative or foul-smelling ulcers, apply metronidazole gel 0.75% into the ulcer bed before applying the dressing to control bacterial overgrowth
  • Pentoxyfylline 400 mg three times daily may result in more rapid healing of venous stasis ulceration
  • Venous ulcers can be very painful. Usually the pain resolves once a granulating base is formed. Provide adequate oral analgesia and monitor the severity of the pain. Often pain reduction parallels or precedes ulcer healing
  • Subsequent treatment steps:
    • After ulcer heals, carefully continue the program of edema control. Support hose with at least 30 mm Hg compression are essential for all patients with healed leg ulcers
    • If the ulceration fails to heal, cultured human keratinocyte or human skin equivalent grafting can be considered. These grafts are not permanent but are effective in converting non-healing leg ulcers into healing ones. They are also very effective in pain control

General discussion

  • Chronic venous insufficiency stems from the acquired incompetence of venous valves that prevent retrograde blood flow through the venous system, resulting in complications, including edema, prominent veins, stasis dermatitis and ulcers
  • Leg ulcers are common complications of chronic venous insufficiency
    • 60% of leg ulcers are due to venous insufficiency, with 30% more associated with a combination of arterial and venous insufficiency
  • Venous insufficiency-related leg ulcers may become chronic wounds, and barriers to effective wound healing include:
    • Ongoing edema (if compression is not incorporated into wound care)
    • Infection
    • Poor arterial vascular supply to the area
  • The medical treatment of leg ulcers due to venous insufficiency requires the consideration of important differential diagnoses of leg ulcers, management of leg edema, monitoring for wound infection and proper wound care

 First-line therapy for treatment of chronic venous insufficiency-related leg ulcers:

  • Consideration of important differential diagnoses of leg ulcers, management of leg edema, monitoring for wound infection and proper wound care
  • Stasis ulcers are the most common cause of leg ulceration. Evidence of venous insufficiency may be minimal, so in some cases vascular evaluation (by Doppler ultrasound) may be required to confirm venous insufficiency as the etiology of the leg ulcer. In all ulcerations, if appropriate and progressive healing does not occur, a biopsy is indicated. Patients with a tendency for lower leg ulcerations may have inherited or acquired defects in their fibrinolytic systems. Appropriate evaluation for these conditions is indicated, especially if there is a history of prior venous thrombosis. Arterial insufficiency may coexist. Determining the ratio of the diastolic blood pressure in the leg versus the arm (ankle brachial index [ABI]) is recommended in all patients, as standard methods for healing venous ulcerations may be ineffective in the presence of significant arterial disease (arterial insufficiency is suggested when the ABI is <0.5-0.7)

 Treatment first steps:

  • Control edema and dermatitis. The former is essential for improvement of the leg ulcer
  • Monitor and treat for infection: Excessive drainage, surrounding erythema, tenderness, and failure of a healing ulcer to continue to heal may be signs of infection. Wound cultures are recommended and appropriate antibiotic therapy should be given
    • Note: Most leg ulcers will be colonized with bacteria, so finding bacteria by culture does not diagnose 'infection'. Cultures of leg ulcers are only of value if they are obtained in the setting of clinical findings of infection. The presence of infection is confirmed if treatment for infection improves the patient's symptoms and the appearance of the ulcer
  • Debride the ulcer: If there is firm adherent fibrinous exudate in the ulcer, debridement will accelerate healing. Apply 30% lidocaine in acid mantle base and wait 20 minutes before gently debriding with a curette
    • This can be repeated at each clinic visit until all necrotic debris has been removed from the ulcer bed
  • Daily wound care: If possible, daily cleansing with saline or soap and water with application of a fresh wound dressing is ideal. Apply a multilayered dressing: Petrolatum or an antimicrobial medication at the wound base, petrolatum-impregnated gauze or a non-stick dressing, gauze dressing, with a final wrap with a gentle elasticized bandage to create compression (if there is no component of arterial insufficiency)
  • If daily wound care is not possible, cleanse/change on a weekly basis in the clinic or wound care facility. A typical weekly dressing would include the following:
    • Topical metronidazole or other antimicrobial medication to control bacterial overgrowth
    • Becaplermin to stimulate granulation tissue (in slowly responding ulcers)
    • Desiccated animal collagen (xenograft) if needed to accelerate wound healing (in slowly responding ulcers)
    • A semipermeable dressing over the whole ulceration, sealed at the periphery
  • For exudative wounds, fenestrated or superabsorptive dressings may be used. Unna boot wrap of the whole leg from toes to just below the knee. The final wrap - if no component of arterial insufficiency is present - should be an application of Coban dressing to apply appropriate pressure (30-40 mm Hg). Measure the ulcer on a weekly basis (to document improvement), gently clean and debride the ulcer bed and reapply dressings

 Treatment pitfalls to remain vigilant of with this approach include:

  • A non-healing ulcer may be cutaneous carcinoma (basal cell, squamous cell, etc.) or an inflammatory ulcer (such as pyoderma gangrenosum). Biopsy non-healing ulcerations after 3 months of treatment or if there is concern for an alternative diagnosis
  • The topical antibiotics bacitracin and neomycin should not be applied to leg ulcers due to the high risk for allergic contact dermatitis
  • Oral antibiotics are overused in the management of leg ulcers. Many 'exudative' ulcers represent appropriate exudation indicative of the early phase of wound healing. This will resolve over a few weeks as the ulcer bed is replaced with granulation tissue. Highly exudative ulcers may benefit from daily treatment with a drying compress (such as Burow's soak) and use of a highly absorptive wound dressing to avoid maceration of the wound base
  • Any ulceration that is deep and fails to heal or that develops an undermined 'pocket' at one edge should be evaluated for underlying osteomyelitis with an appropriate radiological studies
  • If arterial insufficiency coexists (especially ABI <0.7), vascular surgical intervention may be required before the ulcer will heal
  • Non-healing venous insufficiency ulcerations frequently occur after surgeries for skin cancers below the knee in elderly people. Before such surgery, perform an ABI and evaluate the patient for venous insufficiency. If significant venous insufficiency exists, consider wrapping the extremity with a support wrap during the post-surgical period
  • Cholesterol emboli, sickle cell disease, polyarteritis nodosa, Buerger's disease, cocaine use and antiphospholipid antibody syndrome may all cause lower leg ulcerations. If the ulcer is atypical or fails to heal, consider appropriate evaluation

Further reading

Bailey E, Kroshinsky D. Cellulitis: Diagnosis and management. Dermatol Ther  2011;24:229-39.

Prakash AV, Davis MD. Contact dermatitis in older adults: A review of the literature. Am J Clin Dermatol  2010;11:373-81.

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