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New therapies can lead to better outcomes in leg ulcers ulcers

Mr Philip Coleridge Smith and Mr John Scurr report on new ways of treating leg ulcers, which involve minimally invasive treatment methods.

Leg ulcers remain a common problem in general practice and lead to considerable costs for healthcare providers. The annual cost of dressing a leg ulcer is in the region of €7,500 to €15,000.

Costs arise from the dressings and other materials consumed and the district nursing time required to treat ulcers. Some need daily dressing and most need dressings once or twice per week.

Leg ulcers arise in the elderly population most frequently, although sometimes, younger patients are affected as well. A range of vascular disorders produces leg ulcers but many patients have more than one factor responsible for
their disease.

The most frequent problems include venous disease in the leg (70 per cent of patients), arterial disease (25 per cent), diabetes (ten per cent), rheumatoid disease and other conditions producing vasculitis (five per cent). Leg ulceration may also arise from trauma, malignant disease or infection.

Skilled clinician

Management of an ulcer depends upon establishing the diagnosis so a skilled clinician with experience in this field should evaluate the affected limb. Clinical examination and colour duplex ultrasonography should be used to assess arterial patency and venous valvular competence.

Blood tests such as an autoimmune profile and complement may detect rheumatoid disease and other vasculitic conditions. Biopsy of the ulcer is indicated if the diagnosis remains unclear or if malignant disease is suspected.

Leg ulcers may arise from squamous cell carcinoma, basal cell carcinoma or malignant melanoma. Sometimes a malignancy will arise in a pure venous ulcer.
Ulcers that are mainly venous in origin can be managed by wound dressing and application of compression bandaging. A wide range of wound dressings is available which facilitate management of the ulcer.

There is no evidence from any clinical trial to show that a particular dressing or topical application will lead to accelerated healing. Neither will systemic antibiotic treatment lead to more rapid healing.

However, several studies demonstrate that higher levels of compression produced by bandaging lead to healing of ulcers compared to less compression or no compression. A number of bandaging systems are in use that permits safe application of high levels of compression 35-50 mm Hg in elderly leg-ulcer patients.

Bandaging is best done by a trained, experienced practitioner of this art; usually by a district or practice nurse. Effective bandaging cannot usually be applied by the patients themselves.

Compression stockings

Many patients can manage with medical compression stockings applied over a suitable dressing. However, strong stockings can be difficult to apply for elderly patients with a weak grip.

In patients with venous disease in the lower limb, abolition of venous reflux commonly leads to long-term healing of ulcers. In a surprisingly large proportion of patients, venous leg ulcers arise from superficial venous reflux rather than as the result of deep vein damage, for example following a deep vein thrombosis.

The ESCHAR Study, published in The Lancet, showed in a randomised controlled trial that patients with leg ulcers who underwent surgical stripping of incompetent saphenous veins obtained better sustained healing compared to those managed by compression bandaging alone.

Ulcer recurrence is a frequent problem following healing achieved by compression bandaging, where the cause of the ulcer is not addressed. Recurrence may occur in as many as 12-25 per cent of patients per year following healing achieved by compression.

The risk of recurrence can be minimised by the application of medical compression stockings. Again, elderly patients may find difficulty in applying strong stockings.
Surgical treatment is an attractive solution for patients with superficial venous reflux, however many elderly patients with leg ulcers are unsuitable for surgery because of other medical problems or are unwilling to undergo any surgical treatment.

Commonly, patients who would benefit from saphenous vein stripping cannot be treated. In recent years, several new methods of ablating varicose veins without surgery have been introduced, allowing minimally invasive treatment. These are practised at the Beacon Clinic.

A technique very suitable for the management of leg ulcer patients is ‘ultrasound guided foam sclerotherapy’, a modern enhancement of conventional sclerotherapy.
In this treatment, intravenous cannulas are placed in the major saphenous trunks, perforating veins and varices under ultrasound guidance. This can be done with a little local anaesthetic in the outpatient clinic.

Sclerosant foam is introduced which destroys the veins in a much more effective way than traditional sclerosants. This technique is widely used to treat varicose veins in Europe, Australia, New Zealand, South America and the USA.

A number of clinical series have been published in which foam sclerotherapy has been used instead of surgery in leg ulcer patients with superficial venous disease. Excellent healing rates have been reported which mirror the authors’ experience. In the UK, this treatment has been used in one centre where most ulcers healed within two to three months of treatment, almost irrespective of the duration of the ulcers.

An alternative to this is endo-venous radiofrequency ablation, in which a catheter is passed along the vein and electrical heating used to destroy superficial saphenous trunks. This too can be performed under local anaesthetic as an outpatient treatment.
The advantage of these methods is that elderly leg-ulcer patients can be treated in the clinic without the need for surgery or general anaesthesia.

Patients who would be suitable for these techniques include those who have an ulcer mainly due to superficial venous disease (including incompetent perforating veins) who are also reasonably mobile. Wheelchair bound and very frail patients are unlikely to benefit from these interventions.

Blood flow

It is common for elderly patients to have peripheral arterial disease, which may prejudice the healing of a leg ulcer, or severely limit the level of compression which can be applied to the limb before the blood flow ceases.

Peripheral ischaemia can now be managed by balloon angioplasty, usually on an outpatient basis. The treatment is carried out by an interventional radiologist under local anaesthesia. Major vascular reconstruction is usually unnecessary.

In summary, leg ulcers are not a lost cause! They may fail to heal for many months or years if the underlying cause is not identified and treated. Patients with malignant ulcers may experience adverse outcomes.

The most common condition giving rise to leg ulcers, superficial venous incompetence of the lower limb, can be managed by ultrasound guided foam sclerotherapy which usually leads to long-term healing of the ulcer in selected patients.

This treatment can be carried out under local anaesthetic as an outpatient. Referral to a specialist with an interest in this condition is worthwhile.

• Mr Philip Coleridge Smith, DM FRCS and Mr John Scurr, BSc FRCS are consultant vascular surgeons at the Vein Clinic at the Beacon Hospital, Sandyford. See www.varicoseveins.ie or www.beacon hospital.ie for more details.

Posted in Cardiovascular on 01 September 2008
Tags: ulcer

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abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

«Previous article | Next article»

New therapies can lead to better outcomes in leg ulcers ulcers

Mr Philip Coleridge Smith and Mr John Scurr report on new ways of treating leg ulcers, which involve minimally invasive treatment methods.

Leg ulcers remain a common problem in general practice and lead to considerable costs for healthcare providers. The annual cost of dressing a leg ulcer is in the region of €7,500 to €15,000.

Costs arise from the dressings and other materials consumed and the district nursing time required to treat ulcers. Some need daily dressing and most need dressings once or twice per week.

Leg ulcers arise in the elderly population most frequently, although sometimes, younger patients are affected as well. A range of vascular disorders produces leg ulcers but many patients have more than one factor responsible for
their disease.

The most frequent problems include venous disease in the leg (70 per cent of patients), arterial disease (25 per cent), diabetes (ten per cent), rheumatoid disease and other conditions producing vasculitis (five per cent). Leg ulceration may also arise from trauma, malignant disease or infection.

Skilled clinician

Management of an ulcer depends upon establishing the diagnosis so a skilled clinician with experience in this field should evaluate the affected limb. Clinical examination and colour duplex ultrasonography should be used to assess arterial patency and venous valvular competence.

Blood tests such as an autoimmune profile and complement may detect rheumatoid disease and other vasculitic conditions. Biopsy of the ulcer is indicated if the diagnosis remains unclear or if malignant disease is suspected.

Leg ulcers may arise from squamous cell carcinoma, basal cell carcinoma or malignant melanoma. Sometimes a malignancy will arise in a pure venous ulcer.
Ulcers that are mainly venous in origin can be managed by wound dressing and application of compression bandaging. A wide range of wound dressings is available which facilitate management of the ulcer.

There is no evidence from any clinical trial to show that a particular dressing or topical application will lead to accelerated healing. Neither will systemic antibiotic treatment lead to more rapid healing.

However, several studies demonstrate that higher levels of compression produced by bandaging lead to healing of ulcers compared to less compression or no compression. A number of bandaging systems are in use that permits safe application of high levels of compression 35-50 mm Hg in elderly leg-ulcer patients.

Bandaging is best done by a trained, experienced practitioner of this art; usually by a district or practice nurse. Effective bandaging cannot usually be applied by the patients themselves.

Compression stockings

Many patients can manage with medical compression stockings applied over a suitable dressing. However, strong stockings can be difficult to apply for elderly patients with a weak grip.

In patients with venous disease in the lower limb, abolition of venous reflux commonly leads to long-term healing of ulcers. In a surprisingly large proportion of patients, venous leg ulcers arise from superficial venous reflux rather than as the result of deep vein damage, for example following a deep vein thrombosis.

The ESCHAR Study, published in The Lancet, showed in a randomised controlled trial that patients with leg ulcers who underwent surgical stripping of incompetent saphenous veins obtained better sustained healing compared to those managed by compression bandaging alone.

Ulcer recurrence is a frequent problem following healing achieved by compression bandaging, where the cause of the ulcer is not addressed. Recurrence may occur in as many as 12-25 per cent of patients per year following healing achieved by compression.

The risk of recurrence can be minimised by the application of medical compression stockings. Again, elderly patients may find difficulty in applying strong stockings.
Surgical treatment is an attractive solution for patients with superficial venous reflux, however many elderly patients with leg ulcers are unsuitable for surgery because of other medical problems or are unwilling to undergo any surgical treatment.

Commonly, patients who would benefit from saphenous vein stripping cannot be treated. In recent years, several new methods of ablating varicose veins without surgery have been introduced, allowing minimally invasive treatment. These are practised at the Beacon Clinic.

A technique very suitable for the management of leg ulcer patients is ‘ultrasound guided foam sclerotherapy’, a modern enhancement of conventional sclerotherapy.
In this treatment, intravenous cannulas are placed in the major saphenous trunks, perforating veins and varices under ultrasound guidance. This can be done with a little local anaesthetic in the outpatient clinic.

Sclerosant foam is introduced which destroys the veins in a much more effective way than traditional sclerosants. This technique is widely used to treat varicose veins in Europe, Australia, New Zealand, South America and the USA.

A number of clinical series have been published in which foam sclerotherapy has been used instead of surgery in leg ulcer patients with superficial venous disease. Excellent healing rates have been reported which mirror the authors’ experience. In the UK, this treatment has been used in one centre where most ulcers healed within two to three months of treatment, almost irrespective of the duration of the ulcers.

An alternative to this is endo-venous radiofrequency ablation, in which a catheter is passed along the vein and electrical heating used to destroy superficial saphenous trunks. This too can be performed under local anaesthetic as an outpatient treatment.
The advantage of these methods is that elderly leg-ulcer patients can be treated in the clinic without the need for surgery or general anaesthesia.

Patients who would be suitable for these techniques include those who have an ulcer mainly due to superficial venous disease (including incompetent perforating veins) who are also reasonably mobile. Wheelchair bound and very frail patients are unlikely to benefit from these interventions.

Blood flow

It is common for elderly patients to have peripheral arterial disease, which may prejudice the healing of a leg ulcer, or severely limit the level of compression which can be applied to the limb before the blood flow ceases.

Peripheral ischaemia can now be managed by balloon angioplasty, usually on an outpatient basis. The treatment is carried out by an interventional radiologist under local anaesthesia. Major vascular reconstruction is usually unnecessary.

In summary, leg ulcers are not a lost cause! They may fail to heal for many months or years if the underlying cause is not identified and treated. Patients with malignant ulcers may experience adverse outcomes.

The most common condition giving rise to leg ulcers, superficial venous incompetence of the lower limb, can be managed by ultrasound guided foam sclerotherapy which usually leads to long-term healing of the ulcer in selected patients.

This treatment can be carried out under local anaesthetic as an outpatient. Referral to a specialist with an interest in this condition is worthwhile.

• Mr Philip Coleridge Smith, DM FRCS and Mr John Scurr, BSc FRCS are consultant vascular surgeons at the Vein Clinic at the Beacon Hospital, Sandyford. See www.varicoseveins.ie or www.beacon hospital.ie for more details.

Posted in Cardiovascular on 01 September 2008
Tags: ulcer