Management of Venous Ulcers Reviewed

Laurie Barclay, MD

April 29, 2010

April 29, 2010 — Diagnosis and treatment of venous ulcers in the family practice setting are reviewed in the April 15 issue of American Family Physician.

"Venous ulcers, or stasis ulcers, account for 80 percent of lower extremity ulcerations," write Lauren Collins, MD, and Samina Seraj, MD, from Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. "Although the overall prevalence is relatively low, the refractory nature of these ulcers increase the risk of morbidity and mortality, and have a significant impact on patient quality of life. The financial burden of venous ulcers is estimated to be $2 billion per year in the United States."

In the United States, the prevalence of venous ulcers is approximately 1%, with possible underlying mechanisms including inflammation causing leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Clinical characteristics predisposing to development of venous ulcers include older age, obesity, a history of leg trauma, deep venous thrombosis, and phlebitis.

On physical examination, venous ulcers are typically irregular and shallow, with granulation tissue and fibrin present in the ulcer base. They are usually located over bony prominences and may be accompanied by lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis.

An open ulcer may persist for weeks to many years, and it tends to recur. Larger ulcer size and longer duration of the ulcer usually signify a worse prognosis. Severe complications of venous ulcers include cellulitis, osteomyelitis, and malignant change.

Conservative Management Options

Leg elevation, compression therapy, dressings, pentoxifylline, and aspirin are conservative management options for venous ulcers supported by research evidence. Leg elevation reduces edema and should be used for 30-minute sessions, 3 or 4 times a day. No single type of dressing has been shown to be superior.

Compression therapy (inelastic, elastic, intermittent pneumatic) is the standard of care and is associated with a decreased rate of ulcer recurrence. Although compression therapy is of proven benefit, the effect of intermittent pneumatic therapy is less evident. The use of topical negative pressure, or vacuum-assisted closure, for venous ulcers lacks robust-supporting evidence.

Either pentoxifylline (400 mg 3 times daily) or aspirin (300 mg daily) is effective when used with compression therapy, and pentoxifylline may be useful as monotherapy.

Intravenously administered iloprost may be beneficial, but supporting data are limited; it is expensive; and it is not available in the United States.

Oral zinc has not been shown to be effective. Although routine use of systemic antibiotics is not recommended, oral antibiotics should be prescribed to patients with suspected cellulitis. Adding the topical antiseptic cadexomer iodine is of unclear benefit, and this drug is not available in the United States.

Hyperbaric oxygen therapy is of no proven benefit.

Surgical Management

For ulcers that are large, of prolonged duration, or not responsive to conservative measures including pharmacotherapy, surgical management may be considered. Although more research is needed regarding the comparative efficacy of various surgical approaches, options include debridement; human skin grafting; and surgery for venous insufficiency, which is associated with a reduced rate of ulcer recurrence and may be helpful for severe or refractory cases. Artificial skin grafting with human skin equivalent may be effective when used with compression therapy, but there are concerns regarding infection transmission.

Key Recommendations

Key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

  • Compression therapy is the standard of care for treatment of venous ulcers and has been proven beneficial (level of evidence, A).

  • In patients with venous insufficiency, leg elevation reduces edema. A regimen of 30 minutes, 3 or 4 times per day, is recommended as adjunctive therapy for venous ulcers (level of evidence, C).

  • For venous ulcer healing, dressings are beneficial, but no specific dressing has been demonstrated to be superior (level of evidence, A).

  • Pentoxifylline (400 mg 3 times daily) may be useful as monotherapy for venous ulcers, and it has been shown to be effective when used with compression therapy (level of evidence, A).

  • Aspirin, 300 mg per day, is effective for venous ulcers when used with compression therapy (level of evidence, B).

"The role of surgery is to reduce venous reflux, hasten healing, and prevent ulcer recurrence," the review authors conclude. "Surgical options for treatment of venous insufficiency include ablation of the saphenous vein; interruption of the perforating veins with subfascial endoscopic surgery; treatment of iliac vein obstruction with stenting; and removal of incompetent superficial veins with phlebectomy, stripping, sclerotherapy, or laser therapy....There is no evidence demonstrating the superiority of surgery over medical management; however, evaluation for possible surgical intervention should occur early."

The review authors have disclosed no relevant financial relationships.

Am Family Physician. 2010;81:989-996. Abstract

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