Skin and Wound Care

Venous Leg Ulcer

An ulcer on the leg or foot in an area that is affected by venous hypertension and chronic venous insufficiency1

Ulcer typically presents on the gaiter region of the leg (the area extending from just above the ankle to below the knee), with a shallow base, attached edges with an irregular border, and moderate to large amount of exudate1

  • Ultimately the purpose of the venous system is to return blood to the heart to be re-oxygenated. Blood returns up the legs from the contraction of the calf muscle pump, and one-way valves ensure a directional blood flow pattern.2
  • Venous insufficiency and venous hypertension occur due to calf muscle pump failure, incompetent valves and reflux in the venous system.1
  • Three abnormalities that result in venous disease1:
    • Valvular reflux: valves malfunction and there is a reversal of normal flow within the vein.2 Risk factors include:
      • Obesity
      • Multiple pregnancies
      • Prolonged sitting or standing (recreation or occupations)
      • History of varicose stripping
    • Obstruction: any source obstructing the venous system leads to increase in venous pressure. Risk factors include:
      • History of DVT
      • May Thurner syndrome (anatomic variant at the left iliac vein)
    • Failure of the calf-muscle pump:
      • joint issues in the lower extremities leading to decreased ROM (arthritis, surgery or trauma)
      • Walking- shuffling gait that does not activate the calf muscle

Assessment

Skin changes1,2:

Chronic venous hypertension eventually causes skin texture and colour changes.

  • Edema: perceptible increase in volume of fluid in skin and subcutaneous tissue, worsens with dependency (i.e., hanging legs or standing) and improves with elevation, measured by indenting with pressure on limb
  • Stasis changes: eczematous changes that make skin vulnerable, with redness and scaling often associated with pruritus
  • Hemosiderin staining: valves fail and red blood cells leak out of capillaries causing the pigment hemosiderin; grey-brown discolouration of the skin in the lower limb
  • Varicose veins: blue, swollen, twisted, deep or superficial veins
  • Ankle flare (corona phlebectatica): abnormally dilated veins around the ankle
  • Lipodermatosclerosis: woody, fibrous hardening of the soft tissue in the lower leg; often presents as a “champagne” shaped lower leg
  • Atrophe blanche: white areas of extremely thin, fragile skin dotted with tiny blood vessels; seen in clients with venous insufficiency; may be painful; these areas are at greater risk for breakdown

Vascular supply:

Up to 40% of patients with venous disease and ulcerations also have significant peripheral arterial disease;2 therefore it is essential to assess for the vascular supply.

  • Physical signs of peripheral vascular insufficiency3:
    • Shiny, thin and dry skin
    • Loss of hair on extremity
    • Poor nail growth
    • Limb is cool to touch 
    • When leg is hanging (dependent) the limb becomes red
    • When limb is elevated it becomes pale/white
    • Claudication and rest pain
  • Capillary refill 
  • Sensation of lower limb: monofilament testing 
  • Pulses: assess pulses on the foot and leg; dorsalis pedis, and posterior tibial 
  • Ankle Brachial Pressure Index5: A numerical figure that indicates the amount of arterial blood flow to the extremity; determined using Doppler ultrasound by comparing the ankle systolic pressure and the brachial systolic pressure with the ABI being a ratio of the two. ABI is used to evaluate the presence of peripheral arterial disease prior to determining the safe and appropriate level of compression therapy needed to treat venous insufficiency.
    • ABPI ​interpretation4
      • >1.40: indicated calcified vessels, may require further testing
      • 1.0-1.40: normal arterial flow
      • 0.91-0.99: borderline arterial flow
      • 0.70-0.90: mild impairment of arterial flow
      • 0.41-0.69: moderate impairment of arterial flow
      • <0.40: severe impairment of blood flow
  • General patient assessment 
  • Family history of varicose veins 
  • Medications that can cause edema: calcium channel blockers, prednisone and anti-inflammatory drugs
  • History of injury or surgery on lower extremities 
  • Co-morbidities: HIV and renal, heart or liver disease are associated with edema 
  • Duration of edema and whether it decreases overnight (edema that doesn’t decrease with elevation may more likely be lymphedema)
  • Any pain or discomfort: tiredness, achy feeling in legs or muscle weakness

Management of Venous Leg Ulcers

  • Corner stone of venous ulcer management.1,2,3 High compression is better than low, and low compression is better than none; the best compression is the one the patient will wear. 
  • Compression therapy helps reduce the ambulatory venous pressure; it improves the calf muscle pump function and decreases reflux in the malfunctioning veins,1 reducing edema.
  • As edema is reduced in legs, a new compression system may be required based on size of limb; do not fit for a compression garment until compression wraps have been used to decrease edema.

Compression therapy systems1,2:

Type Compression Indication
Long stretch (Elastic)
  • High resting, lower activity
  • Immobile/non-ambulatory patient
Short stretch (Inelastic)
  • Low resting, higher activity
  • Patient has pain
  • Mobile/ambulatory patient

Reused with permission from Wounds Canada, 2017.

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Always provide instruction to patients to remove compression wrap if adverse reactions occur (signs of arterial compromise).

Cleansing

  • Wash both legs with pH-balance soap and water1 every time compression wrap is removed, or instruct patient to cut off compression wrap and have a shower in which they wash leg prior to homecare visit.1
  • After washing legs, moisturize legs with unscented or perfumed moisturizer.1
  • Cleanse ulcer with at least 100 ml of cleansing solution with a PSI of 8-15 (using a squeezable container or 30-35 ml syringe and 18-gauge IV).
  • Pat dry excess fluid and apply barrier to peri-wound skin, if required.

Debridement 

  • Removal of necrotic tissue from wound bed, select the debridement method most appropriate for the patient, situation and environment of care.

Dressings1,3

  • Moisture balance: select a dressing that will be able to absorb the exudate from the ulcer; venous ulcers typically have high levels of exudate.
    • Most dressings can be worn under compression therapy wraps; ensure that the exudate is controlled with the dressings selected.
    • Exudate must be managed to avoid peri-wound maceration.
    • Absorbent dressing examples: foam, hydrofibers, alginates, super absorbent composite dressings
  • Bacteria balance: if there are signs and symptoms of a wound infection, consider using an antimicrobial dressing and/or cleaning solution.
    • Many absorbent dressings have an antimicrobial impregnated option.
    • Examples: Silver, iodine,​​ PHMB, gentian violet methylene blue
Elevation can mobilize fluid out of the legs.2 
  • During elevation the feet must be above the hip joint to be adequate to mobilize fluid, for patients who can tolerate that position.
  • Frequent 20-30 minute episodes of elevation throughout the day are recommended.2
  • Clients who are less mobile or immobile will need assistance with elevation; any degree possible is preferred.
Exercises to stimulate the calf-muscle pump1,2,3,5:
  • Ankle range of motion exercise
    • Passive: patient is assisted by caregivers or assistive devices (i.e., using a rolled towel to pull toes upward towards body)
    • Active: done by the patient; options: going from standing flatfooted to standing on toes, pulling toes upward to feel the stretch in the calf
    • Practice proper gait (walking pattern): emphasize walking pattern of leading with heel then rocking onto toes to then push off
As with all wounds, the whole patient must be considered and interventions must be in place to support the management of any patient factor that could impact wound healing:
  • Pain control1,5: pharmacological or non-pharmacological options, dressing selection to decrease pain 
  • Co-morbidity management: diabetes, heart disease, respiratory diseases, obesity
  • Medications impacting healing: there is evidence that pentoxifylline can improve venous leg ulcer healing1
  • Nutrition and hydration: wounds with a large amount of drainage lose proteins and nutrients from wound drainage
  • Mobility and range of motion (ROM): physiotherapy may be indicated for clients to increase ROM to support the activation of the calf muscle pump
  • Psychosocial support/needs: the psychosocial impact of having a VLU needs to be considered and interventions may be required (i.e., patient can be referred to social work)

References

1. Evans, R., Kuhnke J.L., Burrows C., Kayssi A., Labrecque C., O’Sullivan-Drombolis D. & Houghton, P. (2019). Best practice recommendations for the prevention and management of venous leg ulcers. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada.

2. Treadwell T., Fowler E. & Bates-Jensen B.M. (2012). Management of edema. In C. Sussman & B. Bates-Jensen (Ed.), Wound Care A Collaborative Practice Manual for Health Professionals (pp. 477-502). Philadelphia, PA: Lippincott Williams & Wilkins.

3. Brogle, A.M. (2010). Conservative management of arterial ulceration. In J.M. Mcculloch & L.C. Kloth (Ed.), Wound Healing Evidenced-Based Management (pp. 256-275). Philadelphia, Pa: F.A. Davis Company.

4. Wounds Canada Institute Faculty. (2019). How to assess blood flowing using an ankle-brachial pressure index (ABPI) assessment. Wound Care Canada 17(1). Pp. 22-24.

5. British Columbia Provincial Nursing Skin and Wound Committee. (2014). Guideline: Assessment & treatment of lower leg ulcers (arterial, venous and mixed) in adults. Retrieved from: https://www.clwk.ca/buddydrive/file/guideline-lower-limb-venous-arterial/

6. Botros, M., Kuhnke, J., Embil, J., Goettl, K., Morin, C., Parsons, L., Scharfstein, B., Somayaji, R., Evans, R. (2017). Best practice recommendations for the prevention and management of diabetic foot ulcers. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada.