CORE Principles of Managing Venous Leg Ulcers

Windy Cole, DPM:

Hi, I am Dr. Windy Cole, I'm the Director of Wound Care Research at Kent State University College of Podiatric Medicine, and I'm also the Global Medical Affairs Director for Natrox Wound Care.

I think it's really important to have algorithms that are evidence-based in wound management, and venous leg ulcers are some of the most frequently seen ulcer types in our wound care centers, in our clinical practices. Being at the college, I think having these algorithms and these mnemonics are really important to remind people of the pathways they should really be evaluating for our patients.

So the core algorithm for venous leg ulcers is compression, optimizing the wound environment, reviewing other contributing factors, and then really establishing a maintenance plan. Compression is king when it comes to treating venous leg ulcers. We know that we have to control the venous hypertension in order to allow the microenvironment to really be established to support wound healing. So without compression venous leg ulcers won't heal.

Optimizing the wound environment is also very important. Venous leg ulcers are heavily exudating. The endothelium becomes very leaky, and that fluid will unfortunately cause a buildup and then break through the skin, and that little break starts like a bust in the dam and kind of chips away at the skin, and then patients develop an ulcer. So managing that exudate is really important. And if you talk to a patient with a venous leg ulcer oftentimes that's one of their biggest concerns is that this thing leaks profusely. I can't go to my family member's house because if I'm seated for an hour it just strains through. So managing that exudate is also very important.

Other contributing factors need to be addressed with patients too. A lot of times we see a high level of bioburden in these wounds because they are heavily draining, so that fluid management is key, but then also cutting down on the bacteria contamination. We know that these wounds become secondarily infected with pseudomonas, which has an odor to it, so controlling odor, and then also cutting down on some of the bacteria with an antimicrobial is key as well. So using products and dressings that help us manage that is important.

And then establishing a maintenance plan is probably as important as compression. So compression initially, and then compression for life, and having some sort of compression garment that the patient will wear. Those pull on compression garments, although they are medically sound most of our patients can't don them. The dexterity, they lack it, or they can't just bend down or they don't have the strength, so finding a garment that they'll actually be able to wear, be it zipper close or velcro close are important because venous leg ulcers have a high recidivism rate. We know that up to 70% of venous leg ulcers will recur if there's no established maintenance plan.

And educating the patient too, right? A lot of our patients will say oh well, the wound healed, I don't need to wear my compression anymore. But yet a month later they reopened because they didn't wear their compression. So making them understand how important that is, is part of our job as an educator and a clinician.

There's a lot of products on the market, a lot of dressings out there, and finding a dressing that fits this algorithm I think is really important. I tested some of the product line of Hartman. The super absorbent, Zetuvit, was very effective in exudate management. And another thing that's key, and I've used other products that maybe absorb the moisture, but unfortunately there's some bounce back moisture and some maceration around the tissues, and that could be problematic because that can cause the wounds to enlarge. But with the super absorber with Hartman, the Zetuvit, was very successful in fluid management. Using silver products for antimicrobial and collagen products in their portfolio also helped with optimizing the wound environment, and then also helping control other factors that can cause chronicity with the wound. So I felt that those products really fit into that core algorithm well and had very good outcomes for the patients.