Chronic Venous Ulcers a Comparative Effectiveness Review of Treatment Modalities

Introduction

Venous leg ulcers accept affected humans throughout our being. Rex Henry VIII of medieval England reportedly suffered from recurrent venous leg ulcers, with intermittent sepsis theorized to hamper his judgment on state issues.¹ Compression therapy itself is quite ancient, with reported utilize past Hippocrates dating dorsum to the 4th century BC.² Interestingly, compression is still considered the gold standard of handling for venous leg ulcers today.³

Chronic venous leg ulcers are a common, and often difficult to treat, condition encountered in modern medical do across a wide assortment of specialties. Proper treat these patients requires the cooperation of a squad of clinicians and health care providers, from physicians to wound care specialists.⁴ Approximately ane.5–3.0 per 1,000 adults have active leg ulcers, 80% of which develop secondary to underlying venous disease.^ane,five The directly cost of treatment for venous leg ulcers in the U.s. is currently estimated to be between Usa$10,000–US$12,000 per patient. Additionally, significant indirect costs are associated with lost piece of work productivity and other related expenses.ⁱ These unfortunate patients suffer from a lower quality of life due to decreased mobility, pain, and subsequent loss of income.^six,7

Various treatment modalities currently exist for the treatment of chronic venous ulceration, such as compression bandaging, other compressive therapy, vascular surgery for arterial occlusive disease including lower extremity bypass or endovascular procedures, peel replacement and grafting, and various biophysical interventions, also as endovascular surgical interventions in cases of deep vein stenosis, occlusion, or external compression.^four Several trials have shown that healing rates of venous ulcers are <50% at 12 weeks after the showtime of therapy. Other trials have shown that this rate tin be significantly improved with the use of adequate and consequent pinch materials.^8,9 Iliac vein recanalization with stenting has been shown to exist very efficacious in the healing of chronic venous ulcerations.^ten,11 Raju et al^10,11 take shown in multiple studies that the long-term patency and clinical outcomes are excellent. The need for open surgery to correct reflux or obstruction has been drastically reduced; however, such procedures can still be carried out later in the result of stent apoplexy or failure to relieve symptoms.

The options for venous ulcer treatment are conservative therapy with compression, leg elevation, and ambulation; while other therapy options include surgery past means of great saphenous vein ligation and stripping, or less invasive alternatives such as endovascular ablation or foam sclerotherapy. Perforator vein pause is also an option to promote ulcer healing when indicated.¹² Additionally, investigational cell-based topical treatments are currently being studied in the handling of venous leg ulcers.¹³ The general consensus is that both compression and surgery are as effective in promoting ulcer healing and improving patient quality of life; however, surgery has been shown to have a lower rate of recurrence.¹²

A core component of the current direction of venous ulcerations is pinch therapy.^four It has been shown that venous ulcers heal faster when compression therapy is administered.³ In an overview of guidelines from both the Association of Advanced Wound Intendance (AAWC) in 2012 and the Wound Healing Society (WHS) in 2006 (with an update in 2012), consensus is that multiple sustained loftier compression elastic bandages should be used instead of inelastic compression or single component pinch systems, every bit this method has been shown to be more effective.^iv If this is unable to be accomplished, however, compression of any course has been shown to be better than none.³ After a wound has healed, compression stockings should be used lifelong to reduce ulcer recurrence.⁴ In this review, compression therapy options and their role in the treatment of venous ulcers volition be discussed.

Overview of venous disease

Pathophysiology

The venous arrangement is comprised of high capacitance vessels, designed to accommodate large volume changes, such as those that occur with exercise. Pathology, including venous valvular insufficiency and calf musculus pump dysfunction, leads to chronic claret pooling inside the lower extremities with a subsequent increase in venous pressure. This increase in venous pressure is responsible for the signs and symptoms that are then commonly associated with chronic venous illness.^14–16 Persons who take had a prior deep vein thrombosis (DVT) are particularly prone to deep venous insufficiency and post-thrombotic syndrome, which may ultimately lead to ulceration.^17,xviii

Calf muscle pump deficiency, in particular, appears to have a pregnant clan with venous ulceration.¹⁹ Additionally, nutritional deficiency of wound-healing nutrients may play a significant role in the propagation of chronic venous ulcers; especially protein, vitamins C and A, and zinc.²⁰ Obesity also plays a function in the development of chronic venous ulcers, every bit obesity is associated with decreased mobility and subsequent venous stasis.⁴

Etiology of chronic venous ulcers

The true pathophysiological machinery backside ulcer formation from venous hypertension is not entirely clear. There is some literature supporting the pathological changes that occur locally with venous hypertension. These include fibrin cuff formation effectually the microvasculature, which serves as a barrier to oxygen diffusion; impaired gas exchange; local ischemia and epidermal necrosis; white cell entrapment; and inhibition of growth factors, all every bit proposed mechanisms backside the skin breakdown and poor healing.^21–24

A proposed mechanism for the characteristic skin changes associated with venous illness, including ulceration, involves extravasation of blood particles into tissues secondary to increased pressure and capillary filtration, leading to hemosiderin deposition and subsequent hyperpigmentation. Neutrophil accumulation and fibrin breakup trigger inflammation and increased microthrombi, ultimately leading to impaired local oxygen delivery.⁵

Ulcers trapped in the inflammatory stage are unlikely to heal. This may be caused by an imbalance between matrix metalloproteinases (MMPs) and elastase and the MMP inhibitors. Certain dressings can trap MMPs in the form of oxidized regenerated collagen and cellulose, and may help to promote wound healing.⁵

Clinical presentation

Symptoms of chronic venous insufficiency (CVI) are extremely variable and often vague. Symptom patterns commonly include dull pain, leg heaviness, fatigue or restlessness, and swelling that worsen throughout the day. Pruritus, called-for sensations, cramping, peel tension and thickening, and visible varicosities are too common complaints. Unfortunately, CVI is a progressive disease and ordinarily worsens in severity over fourth dimension. Severe affliction may lead to dermatitis, soft tissue edema, hyperpigmentation, lipodermatosclerosis, ulceration, skin erosion, or hemorrhage. Pain associated with CVI is oft exacerbated by pregnancy and variation in the menstrual cycle.²⁵

Signs of CVI are also quite variable. The first sign is typically ankle and calf edema. Early signs also include telangiectasias and visible reticular veins, palpable intradermal veins, and visible larger varicosities. Longstanding disease manifests with more skin changes, such as lusty induration, stasis dermatitis, hyperpigmentation, and finally, with skin ulceration in the most severe form.²⁶

Diagnosis

Venous disease is characterized by the Clinical Etiologic Anatomic Pathophysiologic (CEAP) Arrangement. The grading arrangement goes from C_ane–C₆. C₁ disease is characterized by visible telangiectasias and/or visible intradermal (reticular) veins. Varicose veins incorporate C₂ or C₃ affliction depending on whether or not they are symptomatic (with C₂ being asymptomatic and C₃ existence symptomatic); however, the distinction between C_ii and C_three affliction is rarely fabricated clinically. C₄ disease is composed of those who have trophic peel changes such as pigmentation, eczema, lipodermatosclerosis, and atrophie blanche (hypopigmentation due to cutaneous infarction). C₅ is designated when a healed venous ulcer is in identify, while C₆ disease consists of an active venous ulcer.^1,26–29

Diagnosis of venous illness begins with a thorough history and concrete test. Particular attention should be given toward eliciting whatever history of DVT or prior surgical intervention. Additionally, if present, all lower extremity incisions must be inspected to determine if stab avulsion phlebectomies or saphenous vein stripping has been previously performed.^xxx

When venous disease is suspected, a focused venous Duplex ultrasound should be performed to examine both the deep and superficial venous system. This will ostend the diagnosis and phase of the extent of disease.³⁰ Additionally, patients with C5 or C6 disease are more than likely to have perforator vein insufficiency, and imaging needs to extend to the surface area directly beneath the ulcer beds.^31–33

Review of current compression therapies

The force of gravity causes venous ulceration to occur in the virtually dependent areas of the lower extremities. It has recently been proven that the machinery behind mechanical compression stockings is related to a decrease in the transmural pressure inside the vein wall by increasing the perivenous tissue pressure.³⁴ Compression may also provide boosted benefit by reducing the vein remodeling known to occur in CVI patients.³⁵ Pinch therapy, therefore, counteracts the force of gravity past applying perivenous tissue pressure.⁹ This external pressure provides strength to move fluid from the interstitial space dorsum into the intravascular space, also equally prevent reflux.^36,37 External force per unit area also increases calf-pumping part and induces a valvular mechanism to increase venous ejection fraction, prevent reflux, and decrease ambulatory venous hypertension.^38,39 Compression therapy requires lifelong maintenance to prevent ulcer recurrence.⁵

The parameters responsible for clinical efficiency of compression therapies are the stiffness (force per unit area increase caused by stretching of the compression material), and the interface pressure exerted on the leg.^ix In guild to effectively change standing venous pressure, the external compression force per unit area applied should exceed lx mmHg, which is the pressure required to compress veins effectively while in the dorsiflexed position.⁴⁰ Patients treated with the highest degrees of compression accept the lowest reported recurrence rates.^41,42 Optimizing compression systems over the years has proven to be a challenging endeavor. This is due to different combinations of materials often existence poorly described in trials, use of confusing terminology, and failure to study the proper pressures and the physical properties of various compression products.¹ One must as well ascertain the status of the patient'southward arterial organization in the lower extremities to avert pinch in the face of peripheral arterial disease.

Bachelor compression therapies

For compression therapy of venous leg ulcers, there are currently five materials that are presently utilized. These include: compression bandages, compression stockings, self-adjustable fabric hook and loop fastener (eg, 'Velcro^®') devices, intermittent pneumatic compression pumps, and hybrid devices.⁹ Each of these treatment modalities volition be discussed (Table 1).

Table 1 Comparison of diverse compression materials Annotation: Reproduced with permission of Gale SS, Lurie F, Treadwell T, et al. Boss Wounds. Wounds. 2014:26(1):1–12.9,72

Compression bandages

Bandages are categorized by their operation into retention, support, or compression type bandages.³ When it comes to venous insufficiency treatment, most involvement lies in pinch bandages. Grade 3 bandages are pinch-type bandages, and are classified on the level of compression at the talocrural joint when the bandage is applied in a simple spiral. Course 3a provides light pinch (14–17 mmHg), class 3b provides moderate pinch (18–24 mmHg), class 3c provides high compression (25–35 mmHg), and course 3d provides extra high compression (upwardly to 60 mmHg).^43,44

This nomenclature system has recently been nether scrutiny, and a more complex nomenclature has been proposed. An skilful consensus grouping recommends that a distinction be made between layers and components of various compression bandages.⁴⁰ Additionally, the notion of a 'static stiffness index' (SSI) has been proposed, every bit properties of 'elastic' bandages may become more 'inelastic' due to the friction forces between different components. The new proposal is for SSIs >10 mmHg when a patient moves from supine to standing to indicate inelasticity, and an increase of <ten mmHg to indicate elasticity.⁴⁰

The bachelor pinch bandages can be broken down into the following groups: inelastic bandages (eg, traditional Unna kick; Figure ane), brusk stretch bandages (eg, Double Comprilan^®; BSN Medical, Hull, UK), multiple component short stretch bandages (eg, Coban 2™; 3M Co, St Paul, MN, USA), long stretch bandages (eg, Ace™; 3M Co), and multiple component (multi-layer) bandages (eg, Profore™; Smith and Nephew, London, UK or KTwo^®; Urgo Ltd, Loughborough, UK). They all tend to take a high working pressure, except for the long stretch elastic wraps.^2,v,9,45

Effigy ane Traditional Unna'southward Boot with multiple layers for pinch.

Inelastic bandages have the highest stiffness of all compression materials.^39,46 They are well-tolerated during periods of residuum and do not require daily application, but tend to be messy and require application past trained staff.^2,42 Short stretch wrap systems accept a high stiffness, besides tend to be well-tolerated during periods of rest, do non require daily awarding, and are washable and therefore reusable, simply may skid and crave application by trained staff.⁴¹ Multicomponent curt stretch systems have a high stiffness, do not require daily application, and are well-tolerated during periods of rest, but are not reusable and require application by trained staff.⁴¹ Long stretch elastic wrap tin be practical by the patient or an assistant, merely have a low stiffness, are not well-tolerated when applied with a high force per unit area, and must be removed nightly.^two Multiple component bandages accept a loftier stiffness and are well-tolerated during periods of rest, but are bulky, warm, and not reusable. They require placement by trained staff, but do not require daily application.⁸

Multiple component vs single component pinch bandages

Compression systems tin can secondarily be classified into unmarried layer and multilayer, and also, into multiple versus single component. A multilayer system is 1 in which one bandage is applied in an overlapping manner leading to a multilayer bandage. Graduated compression stockings take a unmarried compression layer. Multiple component systems may take multiple different materials combined into a unmarried compression system. As a whole, information technology appears that multicomponent compression is more effective than single component pinch systems.³

A pop multiple component organization is the four-layer cast (4LB) system (Effigy two). A 4LB has iv components consisting of orthopedic wool, a crepe cast, an rubberband bandage, and an outer layer made of an elastic cohesive bandage. It is important to note that application of multiple layers both increases force per unit area, besides every bit changes the elastic properties of the final bandage due to friction forces betwixt the surfaces of each of the bandages. The cease upshot is a last bandage layer that is less elastic but with increased stiffness (with an SSI >x).^one,ix,39 Multicomponent bandage systems also often incorporate short stretch bandages.¹ These must exist considered when interpreting information regarding multiple component systems.

Figure two Components of a four-layer compression bandage system.

Current moderate-quality evidence supports the use of multicomponent bandages over single component cast systems for the treatment of venous leg ulcers.⁴⁷ A recently performed meta-analysis pooled information from half-dozen trials comparing a 4LB to an short stretch cast organisation. The results showed a xxx% improvement in ulcer healing in the 4LB arm.ⁱ It should exist noted, however, that these results might indicate lack of proper technique when applying SSB compression systems, as studies in the netherlands and Austria showed no significant differences between the two systems with regard to ulcer healing.^1,three 4LB systems accept the additional do good of beingness more cost-constructive than the SSB alternative.^three No specific 4LB system is currently endorsed, every bit all currently marketed systems announced to perform similarly.⁴¹

Compression stockings

Pinch stockings (elastic prescription hosiery) are classified in a manner similar to bandages, according to compression pressure exerted on the limbs. The pressure level is also measured at the level of the ankle. Class one stockings provide light support (14–17 mmHg), grade 2 provides medium support (18–24 mmHg), and class 3 provides strong support (25–35 mmHg). Form 1 stockings are used to treat varicose veins, course 2 are used for more than severe varicosities and help prevent venous leg ulcers, and class 3 are used to care for astringent venous hypertension and severe varicose veins, and likewise assist to prevent new or recurrent venous leg ulcers.^3,48

Compression stockings (Effigy 3) currently come up in ii varieties – as elastic pinch stockings or as ulcer kits (ie, double stockings). Compression stockings are cocky-applicative, only can exist difficult to put on and tend to have lower working pressure level than their pinch bandage counterparts. They allow for daily skin care and showers. The only deviation in the ulcer kits is that they contain a basal layer that stays in place overnight to keep the ulcer dressing in identify, while the second stocking is placed over information technology daily.⁴⁹

Figure 3 Archetype thigh-high graduated compression hosiery.

Data pooled from iv randomized controlled trials showed that loftier-compression stockings are associated with faster healing than SSB systems at 2–iv months.³ There was also no meaning departure in complete healing between compression stockings compared to two-component and 4LB bandage systems at 3 months. Stockings have the additional benefit of beingness subjected to less operator-dependent variability than are bandages. As a whole, however, studies comparison elastic stockings to inelastic bandages should be interpreted with circumspection, as the bandage force per unit area is extremely variable, and dependent on the stretch applied to the bandage, as well as the experience of the person performing application of the bandage. This makes it difficult to accurately compare the 2 devices.³⁹

Velcro devices

Fabric hook and fastener, ie, Velcro™ devices (eg, CircAid^® Medical Products; MediGLobal, Miami, FL, USA), are self-applicable with patient-controlled adaptable pressure (Effigy iv). They provide medium-to-high stiffness, while allowing for daily skin care and showers. They are the only inelastic compression devices currently on the market that tin can be self-applied past patients. They tend to non be every bit appealing to patients as alternative pinch therapies, nevertheless, due to their bulkiness and restriction of mobility.^ane,xl

Figure 4 Compression with Velcro straps for self-adjustment to permit patient to control pressure.

Intermittent pneumatic compression therapy

Intermittent pneumatic compression pumps, often used for DVT prophylaxis, take been shown to assist in the healing of chronic ulceration.^fifty They can be used with a full pinch organisation, or as an alternative to those patients who are unable to vesture a full pinch organisation.⁵¹ All the same, it is recommended merely when other compression therapies cannot exist used (ie, patients with reduced mobility), are not available, or have failed after prolonged pinch therapy.¹ These devices produce a waveform motion of force per unit area on the leg. In terms of ulcer healing, however, meta-analysis results accept been inconclusive.⁹ The major advantage is that these devices piece of work while the patient is resting.^50,52

Hybrid devices

Hybrid devices (eg, CompreFit BK; Spectrum Healthcare, Phoenixville, PA, USA) combine sustained pinch with intermittent compression therapy, which is utilized during periods of patient rest.^ix They allow for self-application and daily pare care and showers with variable stiffness. Hybrid devices tend to be less appealing to patients as compression alternatives.⁵

Elastic versus inelastic compression

Compression tin can be classified into rubberband and inelastic categories. Elastic bandages have maximal extensibility >100%, and incorporate elastomeric fibers, while inelastic bandages accept a maximal extensibility of <100%.⁵ An intelligent pinch system volition exert strong pressure level in the standing position and low pressure level in the supine position. This difference is referred to as the SSI. The SSI is measured at the B1 point of the gastrocnemius muscle (the transition between the muscular and tendinous portion of the medial gastrocnemius) as the divergence between the resting force per unit area in the lying position and continuing pressure. Another important indicator of bandage stiffness is the pulse pressure level during muscular action, or the walking pressure amplitude (WPA), which is some other indicator of cast stiffness.¹² Pressure produced by compression systems depends on several factors, including the limb size, activity level of the patient, skill of awarding, and application technique.^v

Elastic compression systems exert a small pressure divergence between resting pressure, continuing pressure, and force per unit area during exercise. The SSI is typically <10 mmHg, and the WPA tends to be very depression. Elastic bandages should be applied at 50% of the total extensibility to avoid pain during application.¹² Elastic bandages are effective in edema reduction, but are less constructive than inelastic bandages in improving venous pumping role and subsequent hemodynamics.¹ In order to reach a pressure of >60 mmHg in the upright position, elastic bandages have to exist applied at extremely loftier resting pressures, which would be intolerable for patients.

A contempo Cochrane review ended that the near effective compression systems are multicomponent systems that contain an rubberband bandage.ⁱⁱⁱ The studies that have drawn these conclusions have been called into question, yet, due to proposed flaws in their methodology.³⁹ It is currently accepted that elastic stockings exerting the highest force per unit area tolerable should exist used to foreclose ulcer recurrence after healing.⁴²

Inelastic bandages are not-stretchable textiles. An example is the Unna boot.⁹ Inelastic bandages are well-tolerated, fifty-fifty when applied with a strong initial pressure, due to the immediate reduction in edema and subsequent subtract in leg volume. Inelastic systems also exert a higher pressure during standing, with an SSI >10 mmHg, and peak pressure of >70 mmHg during exercise, bringing inelastic compression systems close to plumbing equipment the definition of an platonic compression system.¹² Studies take concluded that inelastic compression cloth is more effective than elastic bandages at reducing deep venous reflux and superficial venous insufficiency, as inelastic bandages produce much higher continuing pressures than due elastic material.³⁹ Inelastic materials are too more than constructive at improving venous pumping function than elastic materials. Additionally, inelastic material is able to exert a positive result on hemodynamics at pressures as depression as 20 mmHg, which may be benign in the use of mixed arteriovenous ulcers (see adjacent section). The positive effect on ejection fraction exerted by inelastic material was maintained as long as seven days after application despite a decrease in observed force per unit area.⁵³ The lower resting pressure afforded by inelastic bandages makes them more tolerable and less likely to cause pain in patients with arterial illness relative to elastic compression systems.^36,46,54 Previous studies claiming superiority of elastic material relative to inelastic material may have been performed without adequate measurement of the pressure level of the compression devices, and the rubberband dressings in said studies may actually have had properties closer to inelastic dressings.¹² Therefore, information technology is recommended that larger, randomized trials without methodological errors be conducted before any decision is made over which textile is superior in the compression therapy of venous leg ulcers.³⁹

Treatment of arteriovenous ulcers

Up to 30% of lower extremity ulcers take an arterial component. Treatment of mixed leg ulcers (those in which arterial illness is also contributing to ulcer formation) present unique challenges with regard to treatment. Pinch will improve venous hemodynamics, simply can further impair arterial inflow. In a recent study, Mosti et al³⁶ utilized laser Doppler flowmetry (LDF) and transcutaneous oxygen measurements in patients with combined atherosclerotic disease and venous ulcers before and afterwards application of high forcefulness compression to make up one's mind whether or non compression would further impair arterial perfusion. In this limited written report of 25 patients, inelastic compression bandages were applied with pinch pressures ranging from xx–50 mmHg in attempts to identify a cutoff point where arterial perfusion decreased. Claret flow actually increased close to the ulcer (as measured nether bandages) applying all force per unit area ranges, but the amount of increase was greater with bandages applying xx–40 mmHg of pressure. At the toe level, a pregnant decrease in perfusion was noted with bandages that practical >41 mmHg of force per unit area. The authors concluded that for patients with an talocrural joint-brachial index (ABI) >0.5 and an ankle pressure >threescore mmHg, bandages applying up to forty mmHg did not reduce arterial perfusion, and actually improved LDF at the local ulcer level.^36,39

Patients with an ABI of 0.8–1.2, indicative of an adequate lower extremity vascular supply, are adept candidates for high compression therapy. Those with an ABI betwixt 0.five–0.8 should use reduced strength compression and so as to avert distal gangrene and limb loss. For those with an ABI <0.5, compression therapy is contraindicated until a comprehensive vascular assessment deems otherwise.^36,55

Ulcer recurrence

As previously mentioned, the potential for ulcer recurrence without maintenance compression therapy has been reported to exist equally high as 67%.^56,57 When compliant with compression therapy, the reported recurrence rate is 28%. When pinch therapy is combined with superficial venous surgery, the recurrence rate drops to 12%.⁵⁸ As previously mentioned, to prevent ulcer recurrence, elastic stockings exerting the highest pressure tolerable are recommended.⁴²

Supplementation with pharmacotherapy

Supplementation of compression therapy with pentoxifylline (Trental^®; Sanofi SA, Paris, France) has improved healing of venous ulcers, producing an estimated 21% increment in overall healing, with the most normally encountered side effect being gastrointestinal disturbance.⁵⁹ Micronized purified flavonoid fraction has likewise been shown to exist benign in ulcer healing in combination with pinch therapy. However, neither of these pharmacotherapy adjuncts are ofttimes used clinically.^one

Compliance with compression therapy

Compliance remains the Achilles heel of compressive therapy. Reviews accept shown that the benefits of compression therapy diminish according to the level of nonadherence.⁶⁰ As previously mentioned, compression therapy requires lifelong adherence. Compliance with long-term therapy is cited at 37%–67%. Reasons commonly stated for noncompliance include rut accumulation, inconvenience, high toll, and pain.⁶¹ Adherence is also influenced by patient beliefs as to how worthwhile the therapy will be for their condition.⁵⁹ Younger patients often decline compression therapy, while older patients may experience difficulty in applying compressive devices.⁶² Venous leg ulcer recurrence rate is estimated at 26% at ane twelvemonth following consummate ulcer closure.⁶³ Therefore, it is important to determine which interventions are most likely to promote adherence to compression therapy and accordingly counsel and brainwash the patient.

Current therapy for venous leg ulcers usually includes a combination of pinch, possible surgery, concrete therapy, local wound care, drug therapies, and leg ulcer care at community clinics.⁶⁴ Patients often receive either home nursing intendance or attend wound clinics for regular wound intendance. An interesting model for therapy currently existence studied is the employ of community-based clinics designed to increase patient compliance. Unfortunately, systematic reviews are currently unable to determine if these community-based clinics increment patient compliance over standard home or outpatient clinic care.⁶⁴ In two current studies, so-called 'Leg Clubs' are a model designed to provide social back up in a supportive, informative environment.⁶⁴ A like model, known as 'Lively Legs', which evaluates patient lifestyle and beliefs in a customs clinic setting with the aim to promote patient adherence,⁶⁵ has been evaluated in unmarried-centered randomized controlled trials. On review of the Leg Clubs study, information technology was concluded that healing rates and quality of life may not meliorate any more than home-based visits for people with venous leg ulcers; and on review of the Lively Legs study, healing rates, recurrence, and adherence to therapy were not increased more than regular attendance to an outpatient wound clinic.⁶⁴ There is currently limited evidence to truly assess the benefits of community-based nursing models of intendance, and more trials are needed before quality evidence tin be obtained.⁶⁴

Quality of life bug

Not surprisingly, patients with chronic venous leg ulcers suffer from a lower health-related quality of life (HRQOL) because of their illness. Patients written report suffering from pain, slumber disturbance, and increased social isolation because of their illness. In a systematic review conducted on quality of life studies for patients with venous ulcers, the most frequent symptom reported is pain, which was ordinarily described every bit a constant reminder of their disease.⁷ Hurting was reportedly exacerbated during dressing changes and analgesia was often inadequate.^66,67

Patients likewise endure restriction in mobility secondary to ulcer-related pain and leakage of exudate.⁶⁸ In the report by Walshe, many patients felt that inadequate methods were employed to manage exudate and associated odor, leading to increased social isolation and increased self-consciousness.⁶⁸ Another written report echoed these results, finding many patients reporting an disability to maintain hygiene, which contributed to social isolation.⁶⁹ In one quality of life study, it was shown that swelling was a good predictor of impaired mobility, financial trouble, decreased working capacity, and negative furnishings on emotional health. On the other hand, ulcer size was non shown to affect any of these quality of life factors. This report indicated that control of swelling might have a large impact on patient quality of life.⁶ In another written report, investigators adamant that the meaning emotional distress associated with chronic venous leg ulcers frequently goes undetected by care providers.⁷⁰ Patient energy levels were shown to improve with ulcer treatment, with the greatest improvement in energy level noted in those whose ulcer had completely healed.⁷¹ Sleep disturbance is besides a mutual complaint, which is attributable to ulcer-related pain.⁶⁸

In summary, it is recommended that to improve the HRQOL of these patients, intendance providers should individualize strategies to manage wound exudate and subsequent odor, provide comprehensive intendance pathways for ulcer management, foster a collaborative clinician–patient relationship, and provide proper patient educational activity materials.^7,71 Patients may benefit from item attending to reducing their leg swelling.^half-dozen

Decision

Compression therapy remains the aureate standard for treatment of venous leg ulcerations. It is clearly superior with regard to ulcer healing rates compared with no compression.

Current evidence suggests that multiple component bandages (ie, ii-component and 4LB systems) perform better than single component bandages, and compression hosiery appears to perform as well as two-component and 4LB systems, with the boosted benefit of being less operator dependent. Notwithstanding, there is all the same the need for more than high quality research to determine which exact combination of material provides the best overall compression. There is also controversy in the literature over whether inelastic or rubberband compression stockings are superior, and fifty-fifty debate over the definition of rubberband and inelastic materials themselves. It seems clear that elastic stockings exerting the highest pressure level tolerable should be used to prevent ulcer recurrence.

Just every bit important as finding the proper compression organisation, is promoting patient compliance with lifelong compression therapy, given the high rate of ulcer recurrence following successful closure. An improved interdisciplinary approach and enhanced patient educational activity are likely key components. In that location needs to exist more than investigation into ways to ameliorate patient compliance, as this volition lead to decreased morbidity associated with venous affliction.

Disclosure

The authors report no conflicts of interest in this piece of work.

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