Good venous ulcer care a long process

Hospitalists can help by improving diagnosis, follow-up.

Care for venous leg ulcers has evolved over the past 15 years. Wound care specialists are placing more emphasis on assessing the underlying causes of venous ulcers and have adopted new treatments such as minimally invasive ablation procedures and biologically active dressings. But hospitalists, who typically don't receive much training in wound care, often find venous ulcers tricky to diagnose and treat.

Photo by Thinkstock
Photo by Thinkstock.

“There's a high degree of variability in how venous ulcers can look, which can be very confusing,” said Robert M. Plemmons, MD, FACP, medical director of wound care and hyperbaric medicine at Baylor Scott & White Health in Temple, Texas.

Another potential challenge is that venous ulcers can be slow to heal and require ongoing management, Dr. Plemmons said. A patient who hasn't received adequate care or adhered to treatment might be admitted to the hospital multiple times with an infected ulcer.

“Hospitalists need to recognize when the patient's other providers outside the hospital aren't making any headway with healing the ulcer. They should know when to evaluate further and not just accept that an existing diagnosis is correct and that all factors contributing to poor healing have been identified,” said Dr. Plemmons.

To avoid these pitfalls, experts recommend early consultation with whichever specialist at a facility has the most wound care knowledge. “That could be a wound care specialist, a vascular surgeon, a general surgeon, a podiatrist, or another specialist,” said William Marston, MD, chief of the division of vascular surgery and professor of surgery at the University of North Carolina School of Medicine in Chapel Hill.

Differential diagnoses

Venous ulcers develop on the lower leg between the ankle and mid-calf, and most are relatively shallow and irregularly shaped. The affected leg is usually swollen, and the skin surrounding the ulcer typically has reddish-brown discoloration, dermatitis, and ivory-colored scars known as atrophie blanche.

Venous hypertension is the most common underlying cause of lower leg ulcers, accounting for 70% to 80% of these wounds. When the one-way valves in the veins of the legs are dysfunctional (leading to backflow, also known as reflux), the pressure in the veins increases, leading to inflammation in the surrounding tissue, manifested clinically as edema, dermatitis, ulceration, and scarring, said Dr. Plemmons.

When examining a patient with a venous ulcer, one of the first things a hospitalist should check for is any sign of an undiagnosed infection, such as leukocytosis, increased drainage and pain, foul odor, significant redness around the wound, or fever, said Carol Bohanon, DNP, a nurse practitioner at the Vascular Ulcer/Wound Healing Clinic at the Gonda Vascular Center at Mayo Clinic in Rochester, Minn.

Often a patient's baseline venous hyperpigmentation is misinterpreted as infection, so it is important to ask the patient if the erythema is increased from baseline to help determine if a soft tissue infection is present, she said. Oral or IV antibiotics may be needed for a systemic infection.

Another important thing not to miss, said Dr. Marston, is skin cancer that has been misdiagnosed as a venous ulcer. “If the wound hasn't healed after about six weeks of treatment or is missing some of the classic signs of a venous ulcer, like dermatitis in the surrounding skin, it may warrant a biopsy,” he said. In some cases, a patient could have been correctly diagnosed with a venous ulcer but then develop a Marjolin's ulcer, a squamous-cell carcinoma that arises from an ulcer.

Patients with venous ulcers that haven't responded to standard treatments should also be evaluated for peripheral arterial disease, said Dr. Plemmons. While approximately 20% of limbs with venous ulcers have co-existing peripheral arterial disease, “it's not too unusual to find that a patient with a chronic, nonhealing ulcer has never been tested for arterial disease,” he said.

To check for arterial disease, clinicians can palpate the dorsalis pedis and posterior tibial pulses to see if they are weak or absent and examine the foot for signs of ischemia such as atrophy of the skin, hairlessness, or abnormal, dusky redness of the foot with dependent positioning (ischemic rubor).

Ankle-brachial indexes and pulse volume recordings can then be ordered for those with an abnormal exam. These noninvasive tests compare the systolic blood pressures in the ankles to that in the arm and measure blood flow at various points on the legs respectively. The two tests (usually ordered together) can help identify narrowing or blockage of the arteries in the legs, said Dr. Plemmons.

One of the reasons it's important to identify patients with arterial disease is that the standard treatment approach for most venous ulcers includes compression therapy with compression bandage systems or stockings. But if a patient has co-existing venous insufficiency and severe limb ischemia, compression therapy can worsen the ulcer and should not be used, Dr. Plemmons said.

Some venous ulcers won't heal unless the underlying venous insufficiency is addressed. Minimally invasive procedures, such as sclerotherapy and/or ablation with laser or radiofrequency, are often used to shut down blood flow in incompetent veins.

Ms. Bohanon said hospitalists can help begin the process of determining if a patient would be a good candidate for these procedures by ordering a venous duplex ultrasound to determine thrombosis burden and identify incompetent veins and perforators amendable to venous intervention.

“A venous duplex scan is useful for checking for blood clots, confirming whether the patient has venous insufficiency, and identifying refluxing veins that could potentially be treated with surgery,” said Ms. Bohanon.

A patient who has coexisting venous insufficiency and peripheral arterial disease might need an ablation procedure to correct the venous insufficiency and a separate revascularization procedure to increase arterial blood flow to the lower leg in order to achieve healing of the ulcer, Dr. Plemmons said.

Patients with nonhealing ulcers who could be candidates for venous intervention should be referred to a vascular surgeon, interventional cardiologist, or interventional radiologist, Ms. Bohanon said.

Optimizing treatment

“A hospitalist shouldn't expect a venous ulcer to heal during a hospital stay of several days,” said Dr. Marston. “The goal should be to eliminate the things that are preventing the wound from healing.”

That includes elevating the leg above the heart and using compression therapy to control the edema in the leg, removing nonviable tissue and bacteria from the wound bed, and treating an infection with appropriate antibiotic therapy, he said.

Many patients with venous ulcers have comorbid conditions that worsen the edema in the legs, such as congestive heart failure, renal insufficiency, and obesity, Dr. Marston noted. “Those situations are challenging because we have to get the patient to be healthier overall for the ulcer to heal,” he said.

Experts recommend debridement of the ulcer, regardless of whether the wound is infected, during a patient's stay in the hospital and as part of the follow-up care after discharge. Most patients with venous ulcers should receive compression therapy in the hospital, except for those with pulmonary edema or severe arterial disease.

Ms. Bohanon suggests covering the wound with a dressing that will keep it moist and absorb drainage and using compression wraps over the dressing. These layers can be removed fairly easily when clinicians in the hospital need to examine the wound.

“Patients often find compression uncomfortable or bothersome, so clinicians need to notice if they're using the wraps and explain why consistent compression therapy is imperative for healing and preventing re-ulceration,” said Ms. Bohanon.

Hospitalists should also consider prescribing pentoxifylline and aspirin to patients with venous ulcers, said Robert S. Kirsner, MD, PhD, chairman and professor in the department of dermatology and cutaneous surgery at the University of Miami Miller School of Medicine and director of the University of Miami Hospital Wound Center.

“These medications are underutilized, given that they're relatively safe and a number of studies have shown that they can speed healing of venous ulcers,” he said.

Postdischarge care

It's common for a venous ulcer to stop healing after discharge because the patient doesn't elevate the leg or use compression therapy at home and doesn't receive appropriate follow-up care.

“Most of the time when we see patients fail, it's because they didn't receive therapy consistently over time. Venous ulcers generally take between one and six months to heal. Getting patients to comply with therapy over time is not that easy,” said Dr. Marston. Some patients will need to wear compression stockings or bandages indefinitely to prevent ulcer recurrence, said Dr. Marston.

Hospitalists can help set patients up for better outcomes by giving them a referral to a wound care clinic and encouraging them to pursue ongoing care, said Ms. Bohanon. Clinicians at a wound clinic can monitor the wound, perform regular debridements, and help the patient comply with compression therapy.

“One of the important things a hospitalist can do for a patient with a venous ulcer is help to coordinate good follow-up care,” she said.