Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part Two -- Venous Ulcerations

William J. Ennis, DO, MBA, FACOS, Patricio Meneses, PhD


Wounds. 2003;15(4) 

In This Article


Many clinicians are still fearful of using occlusive, moisture-retentive dressings in wound care. Despite an abundance of literature in favor of moist healing, wet-to-dry gauze is still used as a primary therapeutic approach and is considered standard of care by many clinicians. Moisture-retentive dressings should be used in conjunction with compression therapy to manage the venous ulcer patient. No single dressing has been shown to unequivocally improve outcomes, and, in many instances, there are conflicting reports in the literature.[11,110,111,112] Dressing selection, therefore, should be individualized and focus on pain control, exudate management, odor, periwound skin condition, and cost.[5] Moist dressings can aid in debridement, promote granulation tissue formation, and encourage epithelialization. Clinicians continue to use enzymatic agents and topical antimicrobials without definitive proof of efficacy, especially as part of a routine clinical treatment protocol.[18] Patients with venous ulcers become easily sensitized, and some authors believe that venous dermatitis is more frequently a result of topical sensitization than true dermatitis.[113] Numerous studies have failed to definitively correlate bacterial load or the use of systemic antibiotics with healing.[114,115,116,117,118,119,120]

Standard of care, therefore, directs the practitioner towards using a dressing that provides the appropriate level of moisture for optimal healing. Since no individual product has demonstrated improved significant outcomes, the clinician must be familiar with a large spectrum of products. If the patient has failed to show improvement in two to four weeks of adequate compression and a moist environment then a consideration for advanced technologies may be appropriate. Topical growth factors have been evaluated for the treatment of venous ulcers. Initially, expectations were high that growth factor technology would lead to significant improvements in healing outcomes for all chronic wounds. The FDA approved recombinant platelet-derived growth factor with a 10- to 15-percent improvement over placebo for diabetic foot ulcers.[18] It now appears that improvements of this magnitude are actually high because chronic wound healing is multifactorial, and it is difficult to achieve significant improvements with one technology. Epidermal growth factor, transforming growth factor-beta, and tissue plasminogen activator factor have all been evaluated for the treatment of venous ulcers.[121,122,123] At this time, there is no definitive evidence-based support for the use of growth factor therapy for the standard treatment of venous ulcers. Patients failing to respond, however, to individualized compression therapy and appropriate dressings should be considered for these advanced therapies.