Management of chronic venous leg ulcers: A literature-guided approach

Abstract

Venous leg ulcers are a chronic recurrent problem. This disorder has been described in rural, urban, developed, and underdeveloped parts of the world. About 1% of the population will be afflicted with a poorly healing lower extremity wound during their lifetime.1 Estimates of the prevalence of lower extremity wounds in Sweden2 and England3,4 are 0.12 and 0.19%, respectively. Approximately, 40 to 70% of these wounds are believed to have a venous component.2,4,5 Most of these patients were older than 50 and female.4,5 Chronic venous insufficiency with ulceration may occur in up to 3.6% of the population over the age of 15 in Brazil.6 In the 2-year period from 1990 to 1992 there were more than 1.3 million outpatient visits in the United States for venous ulcers.7 As many as 22% of the patients with venous ulcers also have concomitant large vessel arterial disease.4 Because of the chronic and recurrent nature of venous ulcers, these figures may grossly underestimate the prevalence of this disease. The actual costs attributed to this illness are therefore difficult to assess. In Scandinavia treatment was estimated to cost 25 million U.S. dollars in 1985.8 This does not include the loss of productivity and personal suffering that occurs because of this chronic affliction. On the basis of population demographics, estimated costs in the United States would probably be at least an order of magnitude greater.There has been a recent surge in interest in the treatment of these wounds. This has been supported by the advent of new treatments and technologies and a growing interest in gerontology. In 1992 alone more than 100 publications were concerned with venous ulcers. Although several excellent reviews on the treatment and etiology of venous wounds have been published in the past several years,9–16 no consensus exists on the treatment of these wounds. Furthermore, it is difficult to develop a standard care for the treatment of these wounds based on the conventional wisdom of these publications. A consensus standard care or best care would greatly facilitate the health care provided to these patients and would make it possible to have a benchmark against which to compare new treatment modalities. The purpose of this article is to review the recent English literature to develop a consensus standard treatment protocol based on data from published controlled trials.The information used in this article was obtained by a Medline-based search of the literature since 1966. A recent study evaluated this approach for medical problem solving.17 Key search terms were venous, ulcer, leg ulcer, chronic wound, treatment, debridement, compression, topical, and dressing. More than 1200 studies were identified. Literature was reviewed if it was in the English language, the patients studied had venous ulcers, and the trials described were conducted in a randomized controlled fashion. Articles were excluded if it was impossible to determine if the study was controlled and if it was not possible to determine which patients had venous ulcers in a study with more than one wound type. Categories for the protocol were based on typical recommendations for the treatment of patients with chronic wounds. These categories were removal of etiologic cause, wound debridement and infection control, wound cleansing, wound dressings, adjuvant agents (topical, device, or systemic), miscellaneous treatments, and surgical closure. The method section of the controlled trials was tabulated in an effort to determine what was deemed appropriate, standard care.