Venous leg ulcers: Comprehensive management and care

Venous leg ulcer management guidelines and consensus recommendations

There are several guidelines and consensus recommendations for the management of VLU's^1,2. A focus on compression therapy and exudate management is consistent in these guidelines & consensus recommendations^3,4. A comprehensive assessment of the patient, the wound, and the surrounding skin should be made on initial presentation and at frequent intervals to guide ongoing management^1,2,5.

Wound bed preparation and wound assessment

The management of chronic or hard-to-heal wounds relies on the holistic assessment of the person with a wound, using a framework that can help deliver optimal wound treatment.

M.O.I.S.T. is an educational model to help healthcare professionals feel confident in making well-balanced, independent decisions in the topical treatment of chronic wounds. This encourages a systematic approach to wound assessment. 

The M.O.I.S.T. concept provides healthcare professionals with guidance for systematic planning and education with regard to local therapy⁶.

• Moisture Balance
• Oxygen Balance
• Infection Control
• Support
• Tissue

Risk of infection

Chronic non-healing wounds of the lower extremities are susceptible to infection, which can lead to serious complications, such as delayed healing, cellulitis, enlargement of wound size, debilitating pain, and deeper wound infections causing systemic illness^7,8.

Compression therapy and wound debridement can encourage clearing of the infection and help promote healing⁹. Antimicrobial dressings may be used in the short term for the treatment of wound infection¹⁰. There is no evidence to support the routine use of systemic antibiotics to promote healing in a VLU^7,10.

Exudate management in venous leg ulcers

Patients with a VLU generally have an increase in wound exudate when compared with patients with other forms of chronic skin ulcers⁸. Poor management of wound exudate can have a negative effect on patient quality of life and is associated with damage to the wound bed and periwound region, increased risk of infection, delayed wound healing, and increased costs to health services⁸.

Appropriate dressing selection and use in combination with the appropriate and sustained compression therapy work in conjunction to reduce excessive exudate levels².

Compression therapy

Compression therapy is widely recognised as key to the management of a VLU. Compression therapy increases healing rates in comparison with no compression therapy¹¹, and after healing, reduces recurrence rates¹².

A variety of devices are used for compression therapy, including different types of bandages, bandage systems, and garments that provide sustained compression, and pneumatic devices that can apply intermittent compression⁷.

It is essential that the underlying aetiology is established, and arterial disease is excluded before treating a lower leg ulcer with compression therapy. This can be done through a combination of a holistic assessment and simple investigations. In 15-20% of VLU's, an arterial impairment coexists¹³, and these ulcers are known as ‘mixed ulcers’. Arterial impairment is assessed by measuring the ratio between the ankle and the brachial pressure using a test called the Ankle Brachial Pressure Index (ABPI).  In normal patients, a difference of 0.95 is not seen, however in arterial disease an ABPI of <0.8 would warrant further investigation before compression is applied¹⁴. Compression therapy must be avoided in severe, critical limb ischaemia⁷.

The role of dressings in the management of venous leg ulcers

Ulcers of the skin require wound dressings for protection from further trauma, management of wound fluid, and treatment. Because VLU's are associated with high levels of exudate that contain proteases and inflammatory cytokines that may damage surrounding healthy skin, current guidelines recommend the use of wound dressings that manage wound exudate while maintaining a moist wound bed^7,13.

The effective management of wound exudate has been shown to reduce healing time and the risk of skin damage and infection.  Effective wound management also enhances a patients quality of life and improves healthcare clinical and cost efficiencies.

The dressing selected should be²:

• effective under compression therapy, i.e. retain moisture without leaking when placed under pressure.
• atraumatic without damaging the wound bed or periwound skin on removal.
• comfortable and conformable to the wound bed.
• of low allergy potential.
• still intact on removal.
• low profile (unlikely to leave an impression in the skin).
• cost-effective, i.e., offer optimal wear time.