For most of us it is difficult to imagine living with chronic venous ulcer or non-healing wound. But for many patients with poor return blood flow from the legs (venous insufficiency), living with a wound is a reality they cope with on a daily basis. There are the practical issues of wound care, odour control, constant pain, mounting medical costs, being unable to bath or shower their whole body, repeated infections. Living with chronic wounds leads to psycho-social problems too like depression, inability to work, seclusion and hopelessness.
So why don’t venous ulcers heal with good wound care?
The answer is simple. Wound care is treating the symptom, not the cause. The cause is internal, within the veins themselves. The small bi-cuspid valves in the veins need to close rhythmically with each heart beat to help the blood to return to the heart. In a patient with venous insufficiency, this is not happening. The valves don’t close and blood pools in the lower legs causing a brown discolouration to the skin (haemosideran staining), dry and itchy patches of skin (stasis dermatitis) and ultimately a break down in the skin. The lymphatic system is often affected at the same time (phlebolymphedema) which adds swelling to the equation, making it impossible to have any positive outcome with wound care alone.
External compression therapy is changing the lives of these patients. A very simple bandage applied with 20-40mmHg of pressure is enough to compress the bi-cuspid valves into functioning effectively. This alone will start the healing within the wound. Add advanced wound care and you have a scenario where wounds that have been open for 15+ years are healing within 9 -12 weeks.
Advanced wound care is a multi-focal approach to both the wound environment and the overall heath status of the patient. It is important to check for diabetes control and rule out thyroid dysfunction and anemia. Check that the patient is eating enough protein and taking a good daily multi-mineral (with zinc) and vitamin and a probiotic. These patients have usually taken multiple courses of anti-biotics over the years and their immune system needs to be built up.
The wound care itself addresses the following factors:
Moisture control by choosing either the correct absorber to manage exudate or by adding moisture to the wound (a dry wound can’t heal).
Microbial control with non-cytotoxic agents.
Dressing changes every 3-5 days only so as not to disturb cell mitosis.
Appropriate cleansing and wound debridement to remove non-viable tissue.
A picture speaks a thousand words. The wound healing progression pictures below are shared with the permission of my patients. In both cases the wounds had been open for more than 6 years.
Maintenance After Healing
Life long use of compression stockings is needed to maintain closure. There is a 60% recurrence rate in venous ulcer patients. This is due to a gradual non-compliance with compression use a few weeks after healing. It can take 1-2 episodes of recurrence for the patient to accept that compression is needed for life with the rule being ”legs below heart – compression on”.
First prize goes to a stocking that is comfortable and easy to get on and off. I see best results from flat-knit compression knee highs. They are custom made and durable although slightly more expensive than the regular circular knit stockings. But they pay off in the long run.
The two best moments during treatment are the first dressing change, when the patient can see the start of new and positive healing and then when they transition from the bandage to the stocking, skin intact.