Treatment of venous skin ulcers
notes byl dr Claudio Italiano
Compressive therapy
Compression therapy is the standard treatment of varicose ulcers of chronic
venous insufficiency: compression therapy accelerates the healing of venous
ulcers. Available methods include inelastic compression, elastic compression and
intermittent pneumatic compression. Compressive therapy reduces edema, improves
venous reflux, facilitates healing of ulcers and reduces pain. After obtaining
the healing of the ulcer, the maintenance of compression, even for a lifetime,
reduces the risk of relapse. Patient adhesion to compression therapy may however
be limited by factors such as pain, exudation, difficulty in application, as
well as problems such as obesity and contact dermatitis. Contraindications to
compression therapy include clinically significant arterial insufficiency and
uncompensated cardiac failure.
Inelastic compression
Conservative treatment of varicose ulcers
Inelastic compression
provides high external pressure during gait and muscle
contraction, but no resting pressure. The most common method of inelastic
compression is the Unna boot bandage, wet bandage, impregnated with zinc oxide,
which hardens after application. The Unna boot bandage has been shown to improve
healing rates compared to placebo or bandages with water-reactive dressings.
Elastic compression. Unlike the Unna boot bandage, elastic compression methods
adapt to changes in leg size, and maintain compression both at rest and during
muscle activity. Socks or bandages can be used to obtain an elastic compression.
The elastic stockings provide a progressive compression, with a higher pressure
at the ankle level, and progressively decreasing going back to the knee and
thigh (the pressure should be at least 20-30 mmHg, and preferably equal to 30-44
mmHg). The elastic stockings must be removed during the night hours, and must be
replaced every 6 months, since the repeated washes reduce their ability to exert
an effective pressure. An alternative to elastic stockings is elastic bandages.
According to a recent meta-analysis, elastic compression therapy would be more
effective than inelastic compression therapy. High-intensity compression would
also be more effective than low-intensity compression, and multi-layered
bandages would be more effective than single-layer bandages. The disadvantage of
multi-layered compression bandages is that the application should be performed
on an outpatient basis by expert health personnel once or twice a week.
Intermittent pneumatic compression. Therapy by intermittent pneumatic
compression involves the use of a pump that supplies air to inflatable and
deflating sleeves placed around the leg, exerting intermittent compression. The
benefits of this type of intervention are less clear than those described for
standard continuous compression. The method is also expensive, and requires the
immobilization of the patient; intermittent pneumatic compression is therefore
generally reserved for patients who are bed-bound and who are unable to tolerate
continuous compression therapy.
The elevation of the lower limb is indicated during compressived
bendages, so that the
limb is discharged and the edema is reduced. Once the leg has deflated, the
operator begins to wrap it from the foot, and gradually rises up to the thigh.
First the wet gauze impregnated with zinc oxide ointments is used. Subsequently
the inelastic bandage is fixed on this bandage. This compression therapy is left
to act for a few days and then replaced by a new double bandage, always in the
same way. Within a few months you will get the first results and the limb will
be leaner. It is clear that in order not to lose the work obtained, it is
necessary to use elastic stockings with adequate gradation or monocollants.
Preparations for topical use for varicose ulcers
For this purpose, various preparations are available, including hydrocolloids,
foams, amorphous gels with high water content, creams, other non-adherent
preparations. A meta-analysis of 42 randomized controlled trials involving more
than 1,000 patients showed no significant differences in efficacy between
different topical medications. More expensive preparations, such as
hydrocolloids, would no longer be effective, from the point of view of cure
rates, compared to simple non-adherent preparations. In the absence of
indications of different effectiveness between the various preparations, the
choice should be made on the basis of factors such as economic cost, ease of
application, preferences by the doctor and patient.
The topical application of a negative pressure seems to be more effective in
decreasing the depth and volume of the skin lesion (from any cause), compared to
gels with hydrocolloids. However, there are no studies comparing these
treatments for cynically significant outcomes, such as healing time. The high
quality evidence supporting the negative topical pressure in the treatment of
venous ulcers appears to be inadequate for now.
Treatment
Drugs
pentoxifylline
Pentoxifylline is an inhibitor of platelet aggregation, which reduces blood
viscosity and improves microcirculation. Administered at a dosage of 400 mg. 3
times a day, in combination with compression therapy, pentoxifylline was a
useful adjunctive treatment of venous ulcers. In patients who are unable to
tolerate compression bandages, pentoxifìllin can also be effective as
monotherapy.
Acetylsalicylic acid
Like pentoxifylline, also acetylsalicylic acid (300 mg per day), associated with
compression therapy, is able (with respect to compression therapy alone) to
accelerate healing and reduce the size of the ulcer. In general terms, in the
absence of contraindications to the use of the drug, the addition of
acetylsalicylic acid to the compressive therapy appears advisable.
Iloprost
The synthetic prostacyclin iloprost is a vasodilator drug that inhibits platelet
aggregation. In one study, intravenous administration of iloprost, in
combination with an elastic compression therapy, resulted in a significant
decrease in ulcer healing time compared to placebo. The drug, however, is very
expensive, and the evidence available so far in support of its use appears to be
insufficient.
Zinc by mouth
Zinc is a metal with potential anti-inflammatory effects. In patients with
pilonidal cysts the oral administration of zinc was able to decrease the healing
time. On the other hand, in a recent meta-analysis concerning 6 small studies,
oral zinc administration was not effective in the treatment of venous ulcers.
Antibiotics / antiseptics
In the presence of venous skin ulcers bacterial colonization and overlapping
bacterial infections are frequent occurrences, which contribute to the poor
propensity of wound healing. According to a recent review of the Cochrane
system, involving 22 randomized clinical trials on systemic and topical
administration of antibiotics and antiseptics in the treatment of venous ulcers,
routine oral antibiotic administration does not improve rates of healing.
Comparisons of antibiotics and topical antiseptics, such as povidone-iodine
solution, peroxide preparations, ethacrylate lactate, mupirocin, have described
evidence supporting the administration of the topical antiseptic drug iodic
cadexomer (also not available in the United States) ; Overall estimates from 2
clinical trials suggest that the drug is able to achieve an increase in recovery
rates at 4-6 weeks. However, more high-quality data are required to define more
precisely the actual effectiveness of topical medications. Oral antibiotics are
indicated in the treatment of venous ulcers only in cases where cellulite is
suspected. When osteomyelitis is suspected, it is necessary to look for arterial
pathologies; in these cases the administration of intravenous antibiotics should
be considered for the treatment of the underlying infection.
Hyperbaric oxygen therapy
An additional treatment with hyperbaric oxygen has also been proposed to obtain
the healing of chronic skin ulcers. The treatment has potential
anti-inflammatory and anti-bacterial effects, and is effective in achieving
healing of diabetic foot ulcers. However, the data supporting the use of
hyperbaric oxygen in the treatment of venous ulcers are limited.
Surgical therapy
Acute ulcers (maximum duration 3 months) have a total recovery rate of between
71% and 80%, while for chronic ulcers the cure rate after a 6-month treatment is
only 22%. In light of the low healing rates of chronic ulcers, surgical
treatment should be considered in patients with lesions that appear to be
refractory to conservative treatment.
Debridement of necrotic tissues
In order to facilitate the healing of ulcers, necrotic tissue has been removed
from the bottom of the wound for some time and the "bacterial load" has been
reduced by "debridement". The latter can be conducted using a curette or small
scissors, or it can be enzymatic, biological (using larvae), autolytic. Skin
transplants
Human skin grafts can be used in the presence of ulcers of large venous origin
or refractory to treatment. In this regard, self-transplants can be performed (using
skin flaps or cells obtained from another skin site in the same patient),
allografts (skin flaps or cells obtained from another subject) or artificial
skin grafts ("skin equivalents" "human)
Surgical therapy of venous insufficiency
The objectives of surgical therapy of venous insufficiency are to reduce venous
reflux, promote ulcer healing and prevent recurrence. Surgical options include:
ablation of the saphenous vein; the interruption of the perforating veins by
endofascial endoscopic surgery; the treatment of iliac vein obstructions by
inserting stents; removal of insufficient superficial veins by phlebectomy,
stripping, sclerotherapy, laser therapy.
Link correlati al tema:
malattia tromboembolica
profilassi m. tromboembolica
Venous thromboembolism
coagulazione intravasale disseminata
The varices of the leg
Oral anticoagulant therapy
indice vascolare