Managing leg ulcers - it's not rocket science
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Continuing Medical Education
Managing leg ulcers
– it’s not rocket science
Andrew Jull RN MA(Appl) and Julie Betts RN NPTM MN
Correspondence to: a.jull@ctru.auckland.ac.nz
Andrew Jull is a Research Fellow at the A leg ulcer is generally considered team as appropriate. Diabetic ulcers
Clinical Trials Research Unit in the to be a wound with tissue loss on the are best considered as part of the
lower leg, including the foot, which broader issue of managing the dia-
School of Population Health at the Uni-
has not healed within four to six betic foot and so are not considered
versity of Auckland, Editor for the
weeks of injury or opening of the in this paper. A guideline for man-
Cochrane Wound Review Group, and Co- wound. Internationally chronic ve- aging leg ulcers is available from the
editor of Evidence Based Nursing. He led nous insufficiency is the causative New Zealand Guidelines Group
the development of the New Zealand Leg aetiology for 50% of all leg ulcers, website (www.nzgg.org.nz).
Ulcer Guidelines and his current research with mixed venous/arterial disease
accounting for up to another 20% of Community diagnosis of leg
projects include the HALT Trial, an HRC- ulceration
ulcers. Arterial ulcers, diabetic ulcers
funded multicentre randomised control-
and ulcers caused by a mix of all Diagnosis is usually clinical in pri-
led trial evaluating the effectiveness of three account for the remainder. Al- mary and community care. Given that
manuka honey in addition to compres- though this information is derived venous insufficiency is the most com-
sion for venous leg ulcers. He is the au- from international literature, there is mon presentation, this condition
thor of book chapter on drug treatments no reason to suppose New Zealand should be ruled out first. Apart from
differs significantly. the presence of varicose veins, sev-
for venous leg ulcers in the forthcoming
The period prevalence of leg ul- eral other clinical features point to
book ‘Leg ulcers – A problem based
cers in New Zealand over the course venous disease:
learning approach’. of a year is 0.78/1000 population.1 • Ankle flare – dilated venules and
This is lower than other countries venular capillaries are often ob-
Julie Betts is a nurse practitioner in
and capture-recapture analysis served in the area adjacent to the
wound care for Waikato District Health
(which estimates the number of medial malleolus extending
Board. Her role focuses on the manage- missed cases) suggests the figure is downwards to the sole of the foot.
ment of patients with chronic or com- an underestimate of the actual • Skin hyperpigmentation – the ex-
plex wounds, in both delivering direct prevalence.2 Prevalence of leg ul- trusion of red blood cells through
patient care and service development to ceration increases dramatically with capillaries releases haemosiderin,
age, although ulcers can occur in causing purple through to brown
support best practice and maximise pa-
quite young people and there are discolouration (depending on the
tient outcomes. She is currently estab-
records of people suffering with ve- age of the deposition) usually
lishing specialist wound/leg ulcer clinics nous ulcers for up to 60 years. Leg observed extending from above
throughout Health Waikato. Previous ulcers have considerable impact on the malleolus to mid-calf.
Chairperson of New Zealand Wound Care people’s quality of life in compari- • Venous eczema – skin surround-
Society, founding member of the Inter- son to the general population; the ing may be dry, flaky or scaly or
impact is of an order similar to that more vesicular and weeping.
national Union of Wound Healing Soci-
of diabetes and arthritis.3 • Lipodermatosclerosis – progres-
eties. She is currently a member of the
The management principles for sive fibrosis giving the legs a
education committee, International Un- leg ulceration are relatively simple; ‘woody’ induration above the an-
ion of Wound Healing Societies and the identify the underlying condition, kle and the appearance of in-
National Leg Ulcer Working Party (NZ). correct or palliate the condition, and verted champagne bottles (so
include other members of the health called ‘champagne legs’).
Volume 33 Number 3, June 2006 197Continuing Medical Education
• Atrophie blanche – slightly grey spond to treatment, should be inves- tolerate. Bandaging systems that
or white depressed patches milli- tigated for squamous cell or basal cell achieve high levels of compression
metres in diameter, generally carcinomas. are more effective at healing venous
found around and above the me- Leg ulcers commonly occur in ulcers.4 In order to reduce variation
dial malleolus. patients who have rheumatoid arthri- of bandaging pressures, staff who
• Pain – approximately 30% of pa- tis. The underlying aetiology of rheu- have received training in their ap-
tients with venous ulcers will also matoid ulcers is multi-factorial and plication should apply compression
have a painful ulcer. may be due to poor venous return, bandages. Compression bandaging is
• Venous ulcers are usually shallow, vasculitis and/or arterial insuffi- usually available through district
moist, irregular in shape and com- ciency. Rheumatoid ulcers clinically nursing services.
monly occur in the area defined appear the same as venous, arterial Venous ulcers can occur in the
by the lower third of the calf to or vasculitic ulcers depending on presence of arterial disease (ABI 0.6–
2.5cm below the malleoli. which underlying aetiology is pre- 0.8) and these ulcers can still be
The patient may have a history of dominant. They can be large, shal- treated with compression. However,
DVT, leg trauma (fracture, crush or low and granulating, or deep, such patients should receive lighter
major laceration), treatment for vari- punched out and sloughy, or a com- compression and be closely moni-
cose veins, prior history of ulcera- bination of all of these. Rheumatoid tored for any signs of arterial com-
tion or family history of venous dis- ulcers are usually painful. Due to the promise. While increases in pain can
ease. complex nature of these ulcers spe- signal the onset of infection, pain
In order to rule out arterial in- cialist assessment is recommended. could in these patients also indicate
sufficiency, inflow should be assessed critical ischaemia. Patients with mixed
using a handheld Doppler to deter- Treatment
mine the Ankle Brachial Index (ABI). Treatment follows accurate identifi- Box 1. Compression systems
Simple palpation for ankle pulses is cation of aetiology. External com-
inadequate. An ABI is the ratio of pression for leg ulcers is the main- Single layer systems
systolic blood pressure at the arm stay of venous ulcer management. It • Class 3a: light compression. Band-
over that at the ankle; a ratio of >0.8 was probably Richard Wiseman
ages that apply 14–17mmHg at the
usually rules out significant arterial (1622–1676), surgeon to Charles II,
disease. District nurses can obtain an who appreciated the relationship be- ankle.
ABI if venous ulceration is suspected. tween ulceration and circulatory pa- • Class 3b: moderate compression.
If the ABI is 0.6–0.8, mixed disease thology. Wiseman coined the term
Bandages that apply 18–24mmHg
is present and further vascular stud- ‘varicose ulcer’ and developed a
ies may be indicated, especially if the laced stocking made of dog leather at the ankle.
clinical picture does not suggest ve- to compress the leg and eliminate • Class 3c: high compression. Bandages
nous disease. Arterial ulcers have a venous oedema.
that apply 25–35mmHg at the ankle
punched out appearance, a poorly There are many ways of applying
perfused base often covered with compression: compression stockings, when applied as a simple spiral.
slough, and are pale and dry. The short-stretch bandages or inelastic
Multilayer systems
surrounding skin is often taut and systems, rigid paste systems (e.g.
shiny, with dependent rubor. Symp- Unna’s boot) and multilayer elastic • Short-stretch/inelastic: orthopae-
toms of rest pain at night or inter- bandages (see Box 1). Each system dic wool plus 1–3 rolls of short-
mittent claudication with walking has its proponents, although
stretch bandage.
usually accompany arterial ulcera- multilayer bandages are thought to
tion. An ABIContinuing Medical Education
Figure 1. Treatment algorithm for leg ulceration
Leg ulcer > 6 weeks duration
History and clinical exam
Patient diabetic YES
Consider specialist referral
or rheumatoid
NO
Obtain ankle brachial index
ABI 0.8
Trial low Trial high
Moist wound
compression for compression for
dressings
3/12 3/12
Ulcer NO Ulcer
Consider vascular
referral if candidate improving improving
for revascularisation
YES Consider adding YES
pentoxifylline, or consider
complications or
reconsider diagnosis
Continue therapy Continue therapy
NO Ulcer Ulcer NO
healed healed
YES Compression stockings. YES
Consider referral if
Ulcer rceurs likely candidate for
vein surgery
Volume 33 Number 3, June 2006 199Continuing Medical Education
venous-arterial ulcers should be in- sue, reducing the risk of infection, Box 2. Common sensitisers
structed to remove their bandages if and comfort. Compression therapy is
• Wool alcohols, amerchol L101 (bath
increasing pain is present and to con- contra-indicated.
tact a health professional as soon as Management of rheumatoid ulcers additives, creams, emollients)
possible. depends on the underlying aetiology. • Parabens (medicaments, creams)
Topical treatment of venous ul- Assessment by a specialist in leg ul-
• Cetyl alcohol, stearyl alcohol (creams,
cers is not complex. The ulcers can cer management or vascular special-
be cleansed with either sterile saline ist is recommended. Improvement in ointments)
or drinking quality tap water. Patients peripheral arterial inflow, venous • Fragrance mix, balsam of Peru (bath
can remove their bandage and bathe return and optimal management of
oils, moisturisers, baby products)
immediately prior to the visit by the the rheumatoid arthritis is required
district nurse to reapply the band- to heal these ulcers. If compression • Colophony, ester of rosin (adhesive
age. Necrotic tissue can be debrided bandaging is required it should be bandages and dressings)
and simple non-adherent dressings applied with care to avoid damage
• Neomycin, framycetin, bacitracin
applied underneath compression. to bony prominences, which are
Routine topical antibiotics are un- more susceptible to trauma in patients
necessary and topical agents should with rheumatoid arthritis due to der-
generally be avoided, as patients with mal thinning. Topical treatment of Box 3.
venous ulcers are very prone to con- rheumatoid ulcers should focus on
tact dermatitis. Dermatitis will usu- removing slough and necrotic tissue, Pentoxifylline (Trental) is rheological
ally resolve following removal of reducing the risk of infection and agent that has been available since the
common sensitisers and treatment comfort. 1970s. Although results from individual
with a topical steroid (see Box 2). The
patient should also be encouraged to Prognosis trials are varied, an update of a Cochrane
exercise regularly (i.e. walking), el- About five out of every 10 people review found an overall effect in favour
evate their leg above the heart when will still have a venous ulcer after of pentoxifylline for trials where the drug
resting, and to include adequate 12 weeks of compression bandag-
amounts of protein in their diet. ing, and these patients comprise a was used in addition to compression. It
Although there are many adjuvant cohort that may benefit from may also be effective in patients who
treatments for venous ulcers, there adjuvant treatments. However, it has refuse or cannot tolerate compression.
is an absence of evidence for most. not been possible to identify these
Laser therapy, ultrasound, electro- patients until relatively recently. Pentoxifylline is generally well tolerated;
magnetic therapy, honey and silver Although the velocity of wound clo- the most common side effects are
dressings, larval therapy (maggots – sure has been reported as a prog- gastrointestinal.
also called biosurgery), hyperbaric nostic index, a more simple method
oxygen, intermittent pneumatic com- exists that discriminates between
pression, skin grafting, topical warm- normal healers and patients likely
ing and negative pressure dressings to remain unhealed even after 24 The prediction rule gives a good
remain treatments that should be weeks of compression bandaging.5 indication of how long a patient
considered cautiously and on a case- This prediction rule allocates 1 point might have to stay in compression.
by-case basis. each for wounds that are greater If a patient’s ulcer is scored 2, then a
The mainstay of managing arte- than 5cm2 (ulcer area determined by protracted healing time is quite likely.
rial ulcers is to improve peripheral measuring maximum length and The advantage of the prediction rule
arterial inflow. Advances in technol- width) and ulcer duration greater is that it allows the early identifica-
ogy mean less invasive options to than six months. Thus an ulcer can tion of patients who are unlikely to
surgery, such as angioplasty, are now be scored 0, 1 or 2. If an ulcer is heal with simple compression, so that
available. Patients with arterial ul- scored 0, one patient in 20 will re- such patients should be considered
cers should be referred to a vascular main unhealed at 24 weeks; if an for adjuvant drug treatments. Such
specialist as a priority, particularly ulcer is scored 1, three to four pa- adjuvants are few (e.g. Daflon) and
in cases where the ABIContinuing Medical Education
2.26).6 Pentoxifylline can be obtained more than lighter compression stock- gery has been shown to reduce 12-
on GP application to HBL, but is only ings (providing 18–24mmHg at the month ulcer recurrence by more than
registered for use in patients with ankle), but more patients are likely half.8 This effect may be limited to
post-thrombotic ulcers that have to be compliant with the lighter patients with superficial or mixed su-
been unsuccessfully treated with grade of compression stocking. How- perficial and segmental deep reflux.
compression for 16 weeks. ever, patients should be encouraged
to wear the highest grade of com- Competing interests
Prevention pression they can tolerate. The stock- Andrew Jull was the principal in-
Once a venous ulcer has healed, pa- ings are now available in a variety vestigator for the HALT (Honey as
tients will need to go into compres- of colours, but usually will need to Adjuvant Leg ulcer Therapy) Trial
sion stockings. Compression stock- be paid for by the patient. (ISRCTN 06161544), which received
ings have been shown to halve the Vein surgery is another option that free product and an unconditional
five-year risk of ulcer recurrence.7 could be considered once a patient’s cash contribution to the operational
Strong compression stockings (pro- ulcer has healed. Although surgery conduct of the trial from Comita NZ
viding 25–35mmHg at the ankle) re- does not influence healing rates in pa- Ltd. Julie Betts, no competing in-
duce the risk of recurrence slightly tients with active ulceration, vein sur- terests declared.
References
1. Walker NK. Epidemiological studies of leg ulcers in Auckland, 5. Margolis DJ, Berlin JA, Strom BL. Which venous leg ulcers will
New Zealand [PhD]. University of Auckland, 2000. heal with limb compression bandages? Am J Med 2000; 109:15–
2. Walker NK, Vandal AC, Holden JK, Rodgers A, Birchall N, Norton 19.
R, et al. Does capture-recapture analysis provide more reliable 6. Jull AB, Waters J, Arroll B. Oral pentoxifylline for treatment of
estimates of the incidence and prevalence of leg ulcers in the venous leg ulcers (Cochrane Review). Cochrane Database Syst
community. Aust NZ J Public Health 2002; 26(5):451–455. Rev [In press].
3. Jull A, Walker N, Hackett M, Jones M, Rodgers A, Birchall N, et 7. Vandongen YK, Stacey MC, Rashid P. The effect of compression
al. Leg ulceration and perceived health: A population based stockings on venous ulcer recurrence. First World Wound Heal-
case-control study. Age Ageing 2004; 33(3):236–241. ing Congress; 2000, 10–13 September; Melbourne.
4. Cullum N, Fletcher AW, Nelson EA, Sheldon TA. Compression 8. Barwell JR, Davies CE, Deacon J, Harvey K, Minor J, Sassano A,
bandages and stockings in the treatment of venous ulcers et al. Comparison of surgery and compression with compression
(Cochrane Review). Cochrane Database Syst Rev. Oxford: Up- alone in chronic venous ulceration (ESCHAR study): randomised
date Software, 2000. controlled trial. Lancet 2004; 363(9424):1854–9.
Disciplinary Action by Medical Boards and
Prior Behavior in Medical School
‘In this case-control study, we found that physicians who were disciplined by state medical-licensing boards were three times as
likely to have displayed unprofessional behavior in medical school than were control students. This association was observed among
graduates of three geographically diverse medical schools, both public and private, and among 40 state licensing boards. Unprofes-
sional behavior as a student was by far the strongest predictor of disciplinary action. Furthermore, the types of unprofessional
behavior displayed by students were associated with subsequent disciplinary actions. Among students who were subsequently
disciplined, the most irresponsible had a risk of later disciplinary action that was eight times as high as that for control students,
and those who were the most resistant to self-improvement had a risk of later discipline that was three times as high as that for
controls. Among students who were subsequently disciplined, students with low MCAT scores and those with low grades in the first
two years of medical school were also at risk for future disciplinary action, but these were associated with, at most, only one quarter
of the risk attributed to unprofessional behavior. Recent objectives for undergraduate and graduate medical education provided by
the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education include professional-
ism as a core “competency.” Our study provides empirical support for its inclusion and also provides concrete data regarding what
is meant by unprofessional behavior.’
Papadakis MA, Teherani A, Banach MA et al. Disciplinary Action by Medical Boards and Prior Behavior in Medical School, New Eng
J Med 2005; 353:2673-2682.
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