EXPERT ANALYSIS FROM THE ANNUAL INTERNAL MEDICINE PROGRAM
ESTES PARK, COLO. (FRONTLINE MEDICAL NEWS) – Successful healing of chronic venous lower-extremity ulcers hinges on a clinician’s ability to obtain patient buy-in for a zealous regimen of external compression, Meg A. Lemon, MD, said at a conference on internal medicine sponsored by the University of Colorado at Denver, Aurora.
“The top nine ways of treating venous leg ulcers are compression,” explained Dr. Lemon, a Denver-area dermatologist in private practice. “You generally don’t have an active patient who’s moving around [and] allowing the calf to squeeze venous blood back into the circulation, so you have to compress externally. I spend a lot of time with patients saying, ‘If we don’t wear the compression stockings and we don’t elevate the legs, the wound will never heal.’ ”
Compression stockings are always the best initial approach to treatment, Dr. Lemon noted. When compression stalkings are used properly, they can be very effective; furthermore, they are both simpler to use than Unna boots and cost much less than pneumatic stockings.
Compression stockings are no longer frumpy – they have gotten hip. Endurance athletes have embraced them as a recovery aid, and they now come in a multitude of colorful styles. It’s best to start patients off at 15-20 mm Hg of compression so they don’t get discouraged by the initial challenges of getting the stockings on and off, Dr. Lemon explained, then work up to at least 30 mm Hg. Application devices that function much like a shoehorn can assist patients in getting the stockings on if they report difficulties.
As soon as patients get out of bed in the morning, their venous pressure skyrockets, and inflammatory compounds start accumulating in their legs: “I tell patients they need to put the stockings on before getting out of bed to pee in the morning,” the dermatologist said.
A meta-analysis has shown that adequate compression, coupled with wound debridement when indicated, resulted in the healing of 57% of longstanding chronic venous lower-extremity ulcers within 10 weeks and of 75% within 16 weeks, she reported.
Elevating the legs has therapeutic benefit as well, but it has to be done right. The legs must be above the heart for hours at a time, such as while sleeping or while laying on a couch to read or watch television. Putting three bed pillows under the entire calf – rather than under the feet – does the job. Simply sticking the pillows under the feet can result in painful knee hyperextension, which can lead to poor compliance.
“We’re all basically large columns of fluid,” Dr. Lemon said. “We stand around or sit all the time, and the fluid pools in our legs because the valves in the veins stop closing properly as we age. The increased pressure in the vein causes the vein to leak inflammatory compounds into the surrounding tissue, producing edema and chronic inflammation. The chronicity of the disease leads to really profound changes in the skin that are extraordinarily helpful diagnostically.”
These cutaneous changes include a dark brown discoloration – reminiscent of rust – because of deposition of hemosiderin in tissues. The skin becomes fibrous, hard, and ulcerated. The end stage of chronic venous insufficiency is lipodermatosclerosis, in which the skin becomes almost immobile and the lower leg takes on a champagne bottle shape because of hardening of the skin close to the ankle.
Venography, long preferred in definitively diagnosing venous lower-extremity ulcers, is giving way to venous duplex ultrasound, which is not quite as accurate but spares patients the pain associated with the older procedure.
Roughly 70% of chronic lower-extremity ulcers are of venous origin, Dr. Lemon noted.
She encounters quite a few patients who are hospitalized for what is mistakenly diagnosed as bilateral cellulitis, when their true problem is chronic venous insufficiency. The patient’s response to two questions makes it easy to differentiate the two disorders. One is, “Do your legs hurt more or itch more?”
“If the legs itch more, the patient doesn’t have cellulitis,” Dr. Lemon explained. “Cellulitis doesn’t itch. Also, ask the patient, ‘When did your legs last look normal?’ They usually say it was years ago. That’s not bilateral cellulitis – an acute problem requiring hospitalization. It’s a chronic problem requiring extensive chronic wound care.”
If the lower leg wound site looks like cellulitis, with redness, swelling, and warmth to touch, but it itches rather than hurts, she noted, it’s probably stasis dermatitis, which is very common in patients with venous lower-extremity ulcers. The treatment is a potent topical steroid.
“Don’t be afraid of potent steroids,” Dr. Lemon said. “There is so much inflammation in those tissues, they need a potent steroid on the leg. I usually prescribe fluocinonide 0.05% because it’s reliably beneficial.”
An exudative venous wound should receive a moist dressing.
“Forget what your granny told you, and stop telling patients their wounds need to breathe,” she cautioned. “Wounds generally need to be suffocated and covered with an ointment like Vaseline. A dry wound heals about six times slower than a moist one; that’s been extensively studied in the dermatology, surgery, and burn literature.”
If, after 5-6 months of Dr. Lemon’s efforts, a patient’s wound still isn’t healing, the dermatologist will obtain a venous surgical consultation. In some reported series, surgical treatment of insufficiency – venous stripping – has resulted in improved healing time and fewer recurrent ulcers.
Dr. Lemon reported having no financial conflicts regarding her presentation.