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## Complete Summary

#### GUIDELINE TITLE

Leg ulcer guidelines: a pocket guide for practice.

#### BIBLIOGRAPHIC SOURCE(S)

Smith & Nephew Ltd. Grace P, editor(s). Leg ulcer guidelines: a pocket
guide for practice. Dublin (Ireland): Smith & Nephew Ltd.; 2006 Jan. 39
p. \[36 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Smith & Nephew Ltd. Grace P,
editor(s). Guidelines for the management of leg ulcers in Ireland.
Dublin (Ireland): Smith & Nephew Ltd; 2002. 44 p.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Leg ulcers, including:

-   Venous ulcers

-   Arterial ulcers

-   Mixed arterial/venous ulcers

-   Other types of leg ulcers (e.g. diabetic ulcers, malignant ulcers,
    rheumatoid ulcers, vasculitis, hypertensive \[Martorell\] ulcers,
    Raynaud\'s phenomenon)

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Treatment

#### CLINICAL SPECIALTY

Dermatology\
Endocrinology\
Family Practice\
Geriatrics\
Internal Medicine\
Nursing\
Surgery

#### INTENDED USERS

Advanced Practice Nurses\
Nurses\
Physician Assistants\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

To provide practical, evidence-based guidelines on the management of leg
ulcers in the Irish setting

#### TARGET POPULATION

Patients in Ireland with leg ulceration

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Assessment**

1.  Medical history

2.  Physical examination

3.  Ulcer examination (site, size, presentation)

4.  Clinical investigations

    -   Blood pressure, weight, urinalysis

    -   Ankle brachial pressure index (ABPI) using Doppler probe

    -   Investigations to exclude other causes

5.  Wound measurement

6.  Identifying hard-to-heal ulcers using \"rule of six\"

**Management/Treatment/Secondary Prevention**

1.  Cleansing and debridement

2.  Appropriate dressing choice

3.  Wound bed preparation

4.  Appropriate use of topical antimicrobials

5.  Compression therapy

    -   Below-knee graduated multi layer compression

    -   Reduced compression

    -   Compression stockings

    -   Intermittent pneumatic compression

6.  Surgery (e.g., varicose vein surgery, subfascial endoscopic
    perforator surgery, skin grafting)

7.  Appropriate management of associated complications (e.g., oedema,
    infection, dermatitis, allergic contact dermatitis)

8.  Referral to vascular or other disease-specific specialist

9.  Patient/family education

10. Follow-up with reassessment

#### MAJOR OUTCOMES CONSIDERED

-   Morbidity

-   Health care costs

-   Early detection

-   Healing rates

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence base for these guidelines came from reviewing several
existing guidelines (CREST, 1998; SIGN 1998 and RCN, 1998, 2000). Where
there is limited evidence available guidelines are based on current best
clinical practice.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

The guideline developers reviewed published cost analyses.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines were peer reviewed by a group of vascular consultants and
nurses.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Assessment**

Accurate assessment is the key to effective ulcer treatment.
Comprehensive assessment identifies ulcer aetiology and factors, which
may delay healing.

Assessment consists of:

-   Medical history

-   Physical examination

-   Clinical Investigations

**Medical History**

Although most ulcers fall into the category of venous (81%), arterial
(10%) or mixed arterial/venous (7%), other causes such as diabetes,
rheumatoid arthritis or malignancy may be responsible. History taking
should record any aspects of past medical history which may suggest
venous disease or non-venous disease, such as previous cardiac surgery,
diabetes, and rheumatoid arthritis (see Table 1 below).

Ulcer history to be recorded may include: previous history of leg
ulcers, sites of previous ulcers, number of recurrences and past
treatment methods.

**Table 1. Past Medical History Suggestive of Venous or Non-venous
Disease**

  -----------------------------------------------------------------------
  **Venous Disease**                  **Non Venous Disease**
  ----------------------------------- -----------------------------------
  Varicose veins                      Ischaemic heart disease, stroke,
                                      transient ischaemic attack

  Deep vein thrombosis in the         Peripheral vascular
  affected leg                        disease/Intermittent claudication

  Phlebitis in the affected leg       Cigarette smoking

  Previous fracture, trauma, or       Diabetes mellitus
  surgery                             

  Family history of venous disease    Rheumatoid arthritis

  Symptoms of venous insufficiency:   Hypertension
  leg pain, heavy legs, aching,       
  itching, swelling, skin breakdown,  
  pigmentation, and eczema            
  -----------------------------------------------------------------------

**Physical Examination**

It is important that both legs are examined lying and standing. Reduced
ankle joint movement is associated with slower healing rates. General
signs and symptoms of venous, arterial and mixed arterial/venous are
outlined in Table 2 below.

**Table 2. Signs and Symptoms of Leg Ulcers**

  -----------------------------------------------------------------------
  **Venous**                          **Arterial**
  ----------------------------------- -----------------------------------
  Varicose veins                      Cold, shiny, hairless skin

  Pigmentation (brown staining of     Absent pedal pulses
  skin)                               

  Eczema                              Poor capillary refilling time

  Oedema                              Dependent oedema

  Ankle flare (dilation of the small  Dependent rubour
  vessels on the medial aspect of the 
  foot)                               

  Lipodermatosclerosis (leg assumes   Foot pulses absent or difficult to
  the shape of an inverted champagne  find
  bottle -- wide at knee narrow at    
  the ankle)                          

  Atrophie blanche (avascular areas    
  of white tissue within the gaiter   
  region)                             

  Foot pulses present                  

  **Mixed Arterial/Venous**\          
  \                                   
  These will have signs and symptoms  
  associated with both venous and     
  arterial disease.                   
  -----------------------------------------------------------------------

*Ulcer Examination*

Assessment of the site, size and presentation of the ulcer is very
important. The condition of the ulcer base and the surrounding skin will
determine treatment.

**Table 3. Ulcer Examination**

  ------------------------------------------------------------------------
  ** **                    **Venous**              **Arterial**
  ------------------------ ----------------------- -----------------------
  **Site**                 Gaiter region, lateral  Anywhere on leg,
                           or medial malleolus     especially toes, feet
                                                   or heel

  **Size**                 Varying size - Size may Small punched out
                           vary from small to full ulcers
                           circumference of the    
                           leg                     

  **Presentation**         Shallow in appearance   Deep ulcers with
                           Granulation tissue      sloughy base; tendon or
                           evident                 bone may be visible
  ------------------------------------------------------------------------

*Assessment of Ulcer: Using Wound Bed Preparation Acronym TIME*

The concept of TIME incorporates the pathophysiology of chronic wounds
such as leg ulcers.

-   **T is for Tissue**: non-viable tissue in the wound delays healing
    through providing a focus for infection and impeding wound closure.

-   **I is for Infection**: a continued inflammatory response leads to
    sustained high levels of inflammatory cytokines and proteases, along
    with diminished growth factor activity.

-   **M is for Moisture**: chronic wound fluid is biochemically distinct
    from acute wound fluid and contains components, which interfere with
    wound healing.

-   **E is for Edge** of wound, advancing or non advancing:
    non-responsive wound cells and excessive protease activity prevent
    migration of the epidermal margin.

Wound Bed Preparation is the management of the wound to accelerate
endogenous healing or to facilitate the effectiveness of other
therapeutic measures.

**Tissue** - Remove non-viable or deficient tissue - may be episodic or
continuous

-   Necrotic Tissue: Sharp surgical debridement if adequate arterial
    supply - alternatively autolytic methods

-   Sloughy Tissue: Autolytic, enzymatic, mechanical or biological
    debridement

**Moisture imbalance** - Correct desiccation and avoid maceration

-   Intervention: Rehydrate/debride (Revisit T)

-   Address Cause: Control oedema by appropriate means. Use moisture
    balance dressings (e.g. foams, alginates, hydrofibres)

**Infection** or inflammation - Diagnose and treat infection or
inflammatory diseases

-   Infection - Diagnosis of infection can be difficult. The
    interpretation of swab results needs to be done with care and always
    consider clinical features. Management of infection may require
    intravenous or oral therapy. Consider the use of modern topical
    anti-microbials. If infection is not resolving after 2 weeks of
    therapy, consider referral or seek advice.

-   Inflammation - Consider inflammatory diseases in ulcers that have
    unusual presentations/appearances and are not responding to first
    line treatment. Confirmation of diagnosis may require specific blood
    tests, biopsy or if in doubt, consider referral.

**Edge** - Consider surgical intervention or advanced therapies if edge
is not advancing and T, I & M have been addressed.

-   Intervention: Surgical debridement

-   Intervention: Reassessment. Consider biological agents, advanced
    therapies or skin grafting.

Selection and interventions will be based on clinician\'s knowledge,
skills, resources, patient choice and cost-effectiveness.

*Identifying the Hard to Heal Ulcer*

Accurate assessment of venous leg ulcers needs to identify patients with
ulcers which may be slow to heal so individual treatment may be planned
to accelerate the rate of healing. It is appropriate to refer these
patients for further vascular assessment. To identify \"slow healers\"
the \"Rule of Six\" may be employed; this rule states that venous ulcers
larger than six centimetres squared, present for six months or more when
treated with compression are unlikely to heal within six months.

  -----------------------------------------------------------------------
  **Rule of Six**
  -----------------------------------------------------------------------
  Ulcer \>6cm^2^ in size

  Ulcer present for \>6 months

  Unlikely to heal with compression in six months
  -----------------------------------------------------------------------

**Clinical Investigations**

Blood pressure, weight, urinalysis and Doppler ankle brachial pressure
index (ABPI) measurements should be recorded in all patients. Additional
blood and biochemical investigations may also be carried out depending
on the patient\'s clinical history (e.g. blood glucose, full blood count
\[FBC\]).

The absence of pedal pulses may indicate arterial insufficiency;
however, palpation alone is inadequate assessment.  Doppler ABPI is an
objective assessment in identifying arterial disease and should be
carried out by staff trained in the area.

*Procedure for ABPI Measurement*

-   Patient should be supine and resting in warm room for 10-15 minutes.

-   The procedure should be explained to the patient.

-   A blood pressure cuff is placed around the upper arm and the
    brachial artery insonated with a Doppler probe.

-   The cuff is inflated until the arterial signal disappears and is
    slowly deflated. The pressure at which the arterial signal returns
    is the systolic pressure.

-   The procedure is repeated on the other arm.

-   A cuff is placed on the lower leg above the ankle protecting the
    ulcer site.

-   The dorsalis pedis and posterior tibial arteries are insonated and
    the systolic pressure recorded for both arteries, as for the arm.

The ABPI is calculated by dividing the highest ankle pressure by the
higher of the two arm pressures.

ABPI =

[A = Highest ankle systolic pressure]{.underline}\
B = Highest brachial systolic pressure

**Caution!**

-   ABPI measurements in patients with diabetes and/or atherosclerosis
    may not be reliable. Patients with these conditions may have falsely
    high readings due to calcification of the vessels.

*Significance of ABPI Results*

-   ABPI of between 0.92 and 1.30: are considered normal

-   ABPI of greater than 1.30: suggests a non-compressible calcified
    artery and is not an accurate reflection of arterial function (e.g.
    diabetes).

-   ABPI of between 0.5 and 0.92: \*\*It is usually considered safe to
    apply graduated compression bandages on patients with venous leg
    ulcers with an ABPI of greater than 0.8. However, if patients cannot
    tolerate the compression there may be greater arterial disease than
    the ABPI indicates and the patient requires referral to a vascular
    clinic for further investigations.

-   ABPI between 0.00 and 0.5: indicates severe peripheral arterial
    disease and requires urgent referral to a specialist vascular
    clinic. Any type of compression treatment is contraindicated in
    these patients.

\*\* Ulcer aetiology may be mixed if symptoms of venous disease are also
present. Mixed venous arterial ulcers with an ABPI of between 0.5--0.8,
may, with careful supervision, be treated with reduced compression of
15--25 mmHg. However, compression bandaging can further compromise
arterial blood supply, and should be avoided until after specialist
vascular assessment.

**APBI**

  -----------------------------------------------------------------------
  **\>1.3**      **Suggest non compressible calcified artery**
  -------------- --------------------------------------------------------
  0.92 - 1.3     Normal

  0.5 - 0.92     Mild/Moderate claudication

  0.35 - 0.50    Severe claudication

  \<0.35         Critical ischaemia
  -----------------------------------------------------------------------

**Venous Leg Ulcers: Treatment**

**Cleansing**

Cleansing of the ulcer should be kept simple and take the form of
irrigation with warmed tap water or saline.

Best practice is to soak the affected leg(s) in a bucket of warm water
lined with a plastic bag. This facilitates the removal of wound debris
and de-scaling of dry skin. In clinical practice the use of an
emollient, such as Hydromol™ or Oilatum™, may be added to the warm water
to help moisturise the leg and facilitate the removal of dry scaly skin.
Occasionally Potassium Permanganate may be used.

**Appropriate Dressing Choice**

A clean dressing technique is acceptable for chronic leg ulcers and
should be aimed at preventing cross-infection, strict asepsis is
unnecessary.

The emphasis of dressing choice is placed on allergen avoidance and
based on simple nonadherent dressings that do not cause damage to the
wound bed. Patients with leg ulcers are prone to contact sensitivity
particularly from wool, alcohols and rubber mixes. Dressings containing
these products should be avoided in clinical practice. Products
containing lanolin and topical antibiotics should also be avoided.

*In uncomplicated ulcers*, simple non-adherent dressings are recommended
as no specific dressing has been shown to improve healing rates.

*In exuding ulcers*, it may be appropriate to choose an absorbent
dressing to help reduce dressing changes (e.g. foam/alginate dressings).

*In painful ulcers*, a hydrocolloid or foam dressing is appropriate.

*In malodorous wounds* there are a variety of dressings that can help
eliminate odour and absorb exudate including charcoal dressings and
alginate dressings. Consider the use of antimicrobial dressings such as,
Cadexomer Iodine dressings (Iodoflex) and dressings impregnated with
silver (e.g. Acticoat, Acticoat Absorbent).

*In macerated wounds* avoid hydrocolloids and film dressings. Choose
absorbent dressings such as foams (e.g. Allevyn foam). Select an
appropriately sized dressing (5 cm larger than the wound to facilitate
absorption) and carefully position so that exudate does not run below
the wound. Use paraffin-based products or zinc paste as a skin barrier.
Silver or Iodine based products can be used if excess exudate is caused
by infection.

*In difficult to heal leg ulcers*, topical antimicrobials should be
considered in wounds that exhibit local signs of infection or show
failure to progress despite appropriate care. Silver and iodine
dressings may be considered. In a recent study, a number of new
sustained slow-release formulations of iodine and silver were found to
reduce bacterial burden safely and efficiently. (See section above
titled \"Identifying the hard to heal ulcer\")

*Infected wounds*: If signs and symptoms of systemic infection are
present choose systemic antibiotics. If signs of local infection only,
consider topical antimicrobials such as silver or Iodine (see chart
below)

*Topical Antimicrobials: When and Where to Use Them in Clinical
Practice*

Your choice of topical antimicrobial dressings in wound management is a
clinical decision and will depend on the bacterial burden of the wound
and the level of exudate. Topical antimicrobials are most appropriate
when used to decrease the bacterial burden in chronic wounds with active
but localised infection.

**Table: Antimicrobial and Dressing Choice**

+-------------+------------+--------------+-------------+------------+
| ** **       |            |              | **Treatment |            |
|             |            |              | Options**   |            |
+-------------+------------+--------------+-------------+------------+
| **Wound**   | **Clinical | **Management | **No -- Low | **Moderate |
|             | Obs        | Aims**       | Exudate**   | to High    |
|             | ervation** |              |             | Exudate**  |
+-------------+------------+--------------+-------------+------------+
| **C         | No visible | Maintain     | No action   | Chose      |
| ontaminated | changes in | clean wound\ | required    | absorbent  |
| Organisms   | wound bed  | \            |             | dressing   |
| present**   | -- wound   | Prevent      |             |            |
|             | healing    | infection    |             |            |
+-------------+------------+--------------+-------------+------------+
| **C         | No visible | Prevent      | Thorough    | Thorough   |
| olonised**\ | changes in | infection\   | cleansing   | cleansing  |
| \           | wound      | \            | and         | and        |
| Organisms   |            | Reduce       | d           | de         |
| present &   |            | bacteria\    | ebridement\ | bridement\ |
| m           |            | \            | \           | \          |
| ultiplying, |            | Prevent      | Consider    | Consider   |
| but no host |            | bacterial    | topical     | topical    |
| reaction    |            | growth\      | anti        | antim      |
|             |            | \            | microbials\ | icrobials\ |
|             |            | If wound     | \           | \          |
|             |            | progresses   | *Chlo       | *Chlor     |
|             |            | towards      | rhexidine*\ | hexidine*\ |
|             |            | healing *No* | \           | \          |
|             |            | treatment\   | Bactigras\  | Bactigras\ |
|             |            | \            | \           | \          |
|             |            | If wound     | Silver      | Cadexomer  |
|             |            | *FAILS* to   | Dressing    | iodine\    |
|             |            | progress,    | ACTICOAT\   | \          |
|             |            | consider     | \           | IODOFLEX\  |
|             |            | AN           | ACTICOAT 7  | \          |
|             |            | TIMICROBIALS |             | Exudate    |
|             |            |              |             | M          |
|             |            |              |             | anagement\ |
|             |            |              |             | \          |
|             |            |              |             | ALLEVYN    |
|             |            |              |             | RANGE      |
+-------------+------------+--------------+-------------+------------+
| **Critical  | Pain\      | ↓Bacterial   | Thorough    | Cadexomer  |
| Colo        | \          | Burden\      | cleansing   | Iodine     |
| nisation**\ | ↑ Exudate\ | \            | and         | IODOFLEX\  |
| \           | \          | Prevent      | d           | \          |
| Organisms   | ↑ Odour\   | bacterial    | ebridement\ | Silver     |
| increasing  | \          | pr           | \           | dressing   |
| and causing | Dis        | oliferation\ | Consider    | ACTICOAT   |
| failure of  | coloration | \            | topical     | ABSORBENT\ |
| wound to    | of         | Remove       | anti        | \          |
| progress    | G          | barriers to  | microbials: | Exudate    |
|             | ranulation | healing      |             | m          |
|             | Tissue\    |              | -   Iodine  | anagement: |
|             | \          |              |             | ALLEVYN    |
|             | Delay in   |              | -   Silver  | RANGE\     |
|             | wound      |              |             | \          |
|             | healing    |              |             | Acticoat   |
|             |            |              |             | Moisture   |
|             |            |              |             | Control    |
+-------------+------------+--------------+-------------+------------+
| **I         | Wound      | Reduce       | Thorough    | Cadexomer  |
| nfection**\ | d          | bacterial    | cleansing   | Iodine\    |
| \           | escription | burden\      | and         | \          |
| S           | as         | \            | d           | IODOFLEX\  |
| uperficial\ | above\*\   | Prevent      | ebridement\ | \          |
| \           | \          | bacterial    | \           | Silver     |
| Infection   | + ↑        | pr           | *Consider   | dressing\  |
| confined to | PAIN\*\    | oliferation\ | topical     | \          |
| level of    | \          | \            | anti        | ACTICOAT   |
| dermis,     | OEDEMA\*\  | *Topical     | microbials: | ABSORBENT\ |
| erythema    | \          | an           | SSD*\       | \          |
| \<2cms      | WOUND      | timicrobials | \           | *Exudate   |
| around      | BR         | indicated    | *FLAMAZINE* | ma         |
| wound       | EAKDOWN\*\ | when:*\      | Silver      | nagement*\ |
| margin      | \          | \            | dressing -  | \          |
|             | FRIABLE    | Ischaemia\   | E.g.\       | ALLEVYN    |
|             | TISSUE\*   | \            | \           | RANGE\     |
|             |            | Devitalised  | ACTICOAT\   | \          |
|             |            | tissue\      | \           | Acticoat   |
|             |            | \            | ACTICOAT 7\ | Moisture   |
|             |            | Superficial  | \           | Control    |
|             |            | infection\   | Iodine      |            |
|             |            | \            | dressings   |            |
|             |            | Resistant    |             |            |
|             |            | organisms    |             |            |
+-------------+------------+--------------+-------------+------------+
| **Infection | C          | Treat        | *Systemic   | CONSIDER   |
| -- Deep**\  | ellulitis\ | s            | An          | topical    |
| \           | \          | ystemically\ | tibiotics*\ | anti       |
| INFECTION   | *Erythema  | \            | \           | microbials |
| -systemic\  | \> more    | Resolve deep | D           | in wounds  |
| \           | than 2 cms | infection\   | ebridement\ | with       |
| Fever,      | around     | \            | \           | ischaemia  |
| rigors      | wound,     | Reduce       | Thorough    | or multi-  |
| chills,     | pain,      | bacteria\    | cleansing   | resistant  |
| hypotension | oedema*\   | \            |             | organisms\ |
| Multiple    | \          | Treat        |             | \          |
| organ       | HOST       | symptoms\    |             | Exudate    |
| failure     | RESPONSE:\ | \            |             | m          |
|             | \          | Remove       |             | anagement\ |
|             | Pyrexia\   | barriers to  |             | \          |
|             | \          | healing      |             | ALLEVYN    |
|             | Inf        |              |             | RANGE\     |
|             | lammation\ |              |             | \          |
|             | \          |              |             | ACTICOAT   |
|             | ↑ Exudate, |              |             | ABSORBENT\ |
|             | pus\       |              |             | \          |
|             | \          |              |             | ACTICOAT   |
|             | ↑Odour\    |              |             | Moisture   |
|             | \          |              |             | Control    |
|             | Probes to  |              |             | Smith &    |
|             | bone\      |              |             | Nephew     |
|             | \          |              |             |            |
|             | New areas  |              |             |            |
|             | of wound   |              |             |            |
|             | breakdown\ |              |             |            |
|             | \          |              |             |            |
|             | Failure to |              |             |            |
|             | heal       |              |             |            |
+-------------+------------+--------------+-------------+------------+

**Measuring Wounds**

Wound area measurements can help practitioners to monitor the
progression of healing and help to identify the slow to heal leg ulcer
early in the consultation process. The most effective way to do this is
to calculate the percentage reduction of wound area over time,
particularly within the first four weeks. A recent review suggests that
a percentage reduction of 30% to 40% over the first two to three weeks
is predictive of healing. Percentage area reduction is also a useful
parameter for assessing a wounds response to treatment. Precise wound
measurements will help to improve the predictive value of healing rates,
facilitate more effective clinical decision-making and ultimately
improve patient outcomes.

*Ways to Measure Wound Surface Area*

-   Approximation of surface area: using contact tracing or ruler to
    measure; length x width.

-   Precise area measurements: using planimetry, mechanical or digital
    (e.g. VISITRAK Wound Measurement System)

-   Planimetry is the precise measurement of the area contained within
    the wound margin tracing or the traced outline of a digital image of
    the wound.

**Compression Therapy**

The mainstay of *conservative* treatment for uncomplicated venous ulcers
(ABPI of \>0.8) is compression bandaging.

-   Appropriate dressing choice

-   Compression therapy

-   Multilayer Bandaging System

-   Reduced Compression

-   Compression Stockings

Compression applied correctly works to:

-   Reduce hypertension in the superficial veins

-   Improve venous return by increasing flow velocity in the deep veins

-   Reduce leg oedema

-   Accelerate blood flow in the microcirculation, reducing tissue
    fibrosis and the resultant lipodermatosclerosis.

*Types of Compression:*

-   Below-knee graduated multi layer compression

-   Reduced compression

-   Compression stockings

-   Intermittent pneumatic compression

Below-knee graduated multi layer compression is the mainstay of
treatment to improve venous return. Graduated compression delivers the
highest pressure at the ankle and gaiter area, gradually reducing
towards the knee.

Reduced compression may be used in patients with mixed arterial/venous
ulcers under specialist supervision.

Compression stockings are recommended for use in treating some ulcers
and after the ulcer has healed to avoid recurrence.

Intermittent pneumatic compression (IPC) is delivered by a pump device
which inflates and deflates bladders incorporated into sleeves that
envelop the ulcerated leg. There is no evidence to demonstrate better
healing rates using IPC when compared to compression alone. However, IPC
may be considered for use in conjunction with compression bandaging or
in patients who cannot tolerate compression bandaging.

Refer to the original guideline for a pictorial guide on leg bandaging.

**Surgery**

Effective ulcer management centres both on local wound care and on
treating the underlying cause of ulceration, venous hypertension.
Surgical interventions for venous ulceration focus either on varicose
vein surgery and subfascial endoscopic perforator surgery (SEPS), or on
specifically treating the wound bed, as in skin grafting. Skin grafting
is usually only considered in long term ulcers which fail to heal with
conservative treatment. Patients with venous leg ulcer(s) and obvious
varicose veins should be referred for evaluation of suitability for
surgical intervention. The ESCHAR study has shown the significant
benefit of superficial venous surgery in reducing ulcer recurrence.

**Follow-Up Care during Treatment**

-   The patient should be holistically re-assessed each week and
    progress recorded.

-   Regular wound measurement will give an accurate indication of ulcer
    progress.

-   Reassess the appearance of the ulcer: its edge (shallow, punched
    out, rolling), base (granulating, sloughy, necrotic), position,
    surrounding skin, odour, and signs of infection.

-   Reassess the ankle brachial pressure index at 12 weeks if the ulcer
    is not fully healed or if it is deteriorating.

Patient education is the key to compliance and both patients and family
need be educated on leg ulcer care. In addition to verbal information
written patient information should be provided. Patients are more likely
to comply with treatment if they are fully informed of the rationale and
options for their management.

Topics for education should include:

-   Compliance with treatment.

-   Good skin care.

-   Care of limbs and avoidance of trauma.

-   Importance of mobility and exercise.

-   Leg elevation when immobile.

**Management of Associated Venous Ulcer Complications**

-   Oedema

-   Infection

-   Dermatitis

-   Allergic contact dermatitis

*Leg Oedema*

Leg elevation encourages venous return and may reduce pain and oedema.
Either elevate the foot of the bed at night or place several pillows
under the bed mattress to assist leg elevation.

*Infection*

Refer to anti-microbial chart above for signs and symptoms of infection.

If there are clinical signs of active infection or cellulitis (e.g.
pyrexia, increasing pain, enlarging ulcer, or cellulitis) wounds should
be swabbed. Antibiotics have little effect on wound healing generally,
and should not be used to treat organisms that have colonized a wound
but are not causing clinical signs or symptoms of infection. Antibiotics
are recommended only if there is evidence of cellulitis or active
infection.

Topical antibiotics are frequent sensitizers and should be avoided if
possible.

Avoid using compression bandaging if there is evidence of cellulitis.

Reapply dressings daily or on alternate days to allow assessment of the
infected area. (See dressing choice and antimicrobial chart above)

*Dermatitis*

Venous eczema is commonly associated with chronic venous ulcers and may
present as diffuse erythema, scaling, haemosiderin pigmentation, and
exudate with crusting if there is superadded infection. Frequent
emollient application (e.g. 50%/50% white paraffin/soft paraffin gel)
plus a short course of mild topical corticosteroid ointment are the
mainstay of treatment.

*Allergic Contact Dermatitis*

Allergic contact dermatitis may complicate venous eczema in a number of
patients.

Common sensitisers include wool, alcohols, topical antibiotics, topical
corticosteroids, cetylstearyl alcohols, parabens, and rubber mixes.
Referral for dermatological patch testing may be appropriate if the
dermatitis does not settle, or if there are concerns about sensitivity
to a topical agent, dressing, or bandage used. Ideally a specific leg
ulcer patch-test series should be used.

**Treatment Outcomes**

*Ulcer Heals -- Follow-up*

Compression stockings

-   Measure and fit patients with class 2 graduated compression
    stockings.

*Measuring the Patient for Compression Hosiery*

Measurements should be taken, with the patient\'s feet flat on the
ground. As a general rule the circumference of both legs should be
measured so that any discrepancies between the two legs can be taken
into consideration.

-   **For thigh length stockings**: with patient standing, Measure the
    thigh mid-region

-   Measure the widest part of the calf

-   Measure the narrowest part of the ankle, above the ankle bone

-   Measure foot length (closed toe hosiery only)

-   To approximate length: measure the length from the thigh to the
    floor/heel

-   **For knee high stockings** measure widest part of calf and
    narrowest part of the ankle

-   Measure from the back of the knee to the floor.

-   Replace stockings every six months

Encourage patients to:

-   Maintain good skin care

-   Remain active

-   Elevate limbs when resting

-   Present early to their general practitioner (GP) or public health
    nurse (PHN) for assessment if ulcer recurs.

*Ulcer Fails to Heal (No Reduction in Ulcer Size after I Month)*

-   Re-assess ulcer (Refer to TIME acronym above to assist in
    re-assessment)

Reasons for referral to a vascular specialist:

-   No reduction in ulcer size after one month

-   Ulcer duration of greater than six months

-   Unable to tolerate compression

-   Uncontrolled pain

-   Frequent recurrence

If there is any doubt about the cause of the ulcer, specialist
assessment is recommended.

**Arterial Ulcers**

Arterial ulcers: Account for approximately 10% of all ulcers.

**Signs & Symptoms**

-   Cold, shiny, hairless skin

-   Absent pedal pulses

-   Poor capillary refilling time

-   Dependent oedema

-   Dependent rubour

-   Foot pulses absent or difficult to find

-   Multiple \"punched cut ulcers\"

**When to Refer**

Patients with a suspected arterial ulcer with an ABPI of \<0.8 need to
be referred for further assessment by a vascular specialist.

Patients with an ABPI of \<0.5 require urgent referral. These patients
may require surgery or angiography. Compression is contra-indicated in
patients with an ABPI of \<0.5 and ulcer care should concentrate on
implementing good wound care practices and appropriate dressings (see
*Significance of ABPI Results* above.

**Mixed Arterial/Venous Ulcers**

*Mixed arterial and venous* insufficiency may be seen in approximately
7% of leg ulcers. Mixed arterial/venous ulcers with an ABPI of between
*0.5 - 0.8* may be treated with *reduced compression* of 15-25 mmHg.

Referral is also appropriate if the ulcer fails to progress to healing.
Mixed ulcers with ABPI of *\<0.5* must *not be treated with compression*
and require urgent vascular referral.

Patients with peripheral arterial disease need to be educated on
lifestyle modification to reduce risks associated with atherosclerotic
disease. This includes education on: smoking cessation, the benefits of
exercise and the importance of a well balanced low fat diet. Aspirin
daily and statins to reduce cholesterol may be considered in medical
therapy.

**Other Causes of Leg Ulceration**

**Diabetic Ulcers**

Diabetic ulcers are typically located on the foot over a bony
prominence. This ulcer may have neuropathic, arterial, and/or venous
components. People with diabetes with an ulcer on the foot require
referral to the specialist diabetic foot clinic or for vascular consult.

**Rare Causes of Ulceration**

-   *Malignant ulcers* on the leg are rare and are usually either
    squamous cell carcinoma, basal cell carcinoma or malignant melanoma.
    Malignancy needs to be considered if the ulcer is unusual in its
    site or appearance and does not respond to conventional treatment.
    These ulcers may require biopsy.

-   *Rheumatoid ulcers* (vasculitic) typically are deep, well-demarcated
    and punched-out on the dorsum of foot or calf. People with
    rheumatoid arthritis might also have venous disease due to reduced
    mobility, neuropathy, and possibly impaired healing due to systemic
    corticosteroids.

-   *Vasculitis* may cause multiple leg ulcers that are necrotic and
    deep. They may present as purpura, erythema, urticaria, nodules or
    bullae.

-   *Hypertensive (Martorell) ulcer* can develop in patients with poorly
    controlled hypertension. This type of ulcer is painful with necrotic
    edges, and is usually sited on the lateral aspect of the lower leg.

-   *Raynaud\'s phenomenon* affects the distal extremities and may cause
    very painful ulceration of the extremities. Scleroderma which may be
    associated with Raynaud\'s can also result in leg ulceration

-   *Other possible causes* include pressure ulcers, traumatic ulcer,
    sarcoidosis, tropical ulcer, or pyoderma gangrenosum.

**Summary on Criteria for Referral for Specialist Consult**

-   Suspected malignancy

-   Arterial/mixed ulcer

-   Diabetes mellitus and ulcer

-   Sepsis

-   Absent pulses with reduced ABPI measurements

-   Failure to heal with standard regime

-   Underlying co-morbidity

-   Deterioration

-   Recurrent ulceration

-   Need for surgery

-   Identified as slow-to-heal ulcer

-   Pain management

If there is any doubt about the cause of the ulcer, specialist
assessment is recommended.

**Challenges in Leg Ulcer Management**

Leg ulcer management is improving as health professionals become more
aware of the importance of early and appropriate treatment. However,
despite improvements there remain many challenges in the care of
patients with this chronic debilitating condition. The core challenges
the guideline authors would identify are:

1.  Improved healing rates among the slow-to-heal group

2.  Greater community hospital links to ensure speedy referral time

3.  Ongoing education.

Refer to the original guideline document for a detailed discussion of
each of these challenges in leg ulcer management.

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document for
assessment, diagnosis, treatment/management and outcomes of leg ulcers.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Accurate assessment of leg ulcers is the key to effective ulcer
    treatment. Comprehensive assessment identifies ulcer aetiology and
    factors which may delay healing.

-   Appropriate management of leg ulcers in Ireland can help promote
    healing and prevent recurrence.

#### POTENTIAL HARMS

*Caution*: Ankle brachial pressure index (ABPI) measurements in patients
with diabetes and/or atherosclerosis may not be reliable. Patients with
these conditions may have falsely high readings due to calcification of
the vessels.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Ankle brachial pressure index between 0.00 and 0.5 indicates severe
    peripheral arterial disease and requires urgent referral to a
    specialist vascular clinic. Any type of compression treatment is
    contraindicated in these patients.

-   Patients with leg ulcers are prone to contact sensitivity
    particularly from wool, alcohols and rubber mixes. Dressings
    containing these products should be avoided in clinical practice.
    Products containing lanolin and topical antibiotics should also be
    avoided.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The guidelines are not intended to replace any existing protocols or
institutional policies.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Smith & Nephew Ltd. Grace P, editor(s). Leg ulcer guidelines: a pocket
guide for practice. Dublin (Ireland): Smith & Nephew Ltd.; 2006 Jan. 39
p. \[36 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2002 (revised 2006 Jan)

#### GUIDELINE DEVELOPER(S)

Smith and Nephew, Ltd. - Private For Profit Organization

#### SOURCE(S) OF FUNDING

Smith and Nephew, Ltd.

#### GUIDELINE COMMITTEE

Leg Ulcer Guidelines Development Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Group Members*: Prof. Pierce Grace, Professor of Surgical Science,
University of Limerick, Ireland and Consultant Vascular Surgeon, Health
Service Executive area, Regional Hospital, Dooradoyle, Limerick; Mary
Clarke Moloney, RGN, Hdip. Research Assistant, Health Service Executive,
Regional Hospital, Dooradoyle, Limerick; Sandra Barrett, BSc Nursing,
Clinical and Education Manager, Smith and Nephew Ltd

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Smith & Nephew Ltd. Grace P,
editor(s). Guidelines for the management of leg ulcers in Ireland.
Dublin (Ireland): Smith & Nephew Ltd; 2002. 44 p.

#### GUIDELINE AVAILABILITY

Print copies and CD-ROM: Available from Smith & Nephew Limited, Carraig
Court, George\'s Avenue, Blackrock, Co. Dublin, Ireland; Phone:
+353-1-217-0444, Fax: +353-1-217-0455; Web site:
<http://www.smith-nephew.com/ie/wound>; E-mail:
<sandra.barrett@smith-nephew.com>.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on February 2, 2004. The
information was verified by the guideline developer on February 16,
2004. This NGC summary was updated by ECRI Institute on May 2, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008