Varicosities (Varicose Veins) Either small or larger vessels First indicator of chronic venous insufficiency is often the presence of a dilated long saphenous vein on the medial aspect of the calf [1] Hemosiderin staining Brown or brownish red pigmentation and purpura (purplish discoloration of the skin produced by small bleeding vessels near the surface) Caused by extravasation (leaking) of red blood cells into the dermis Insoluble form of storage iron collects within the macrophages and melanin deposition occurs Will not disappear over time (internal cause) [2] Chronic Lipodermatosclerosis Lower 1/3 of leg becomes sclerotic (hardened tissue) and woody. Leg becomes champagne bottle or bowling-pin shaped Venous ulcers surrounded by extensively fibrotic (excess connective tissue ) skin Ulcers are more difficult to heal [2] lipodermatosclerosis Hyperpigmentation and hypopigmentation interspersed with telengectasia or tiny blood vessels on the surface Painful and tender panniculitis (inflammation of adipose tissue) Ulcers can occur within the lesion Becomes intensely fibrotic over time [3] Stasis (venous) dermatitis Erythema Scaling Pruritis (itchy) Sometimes weeping May develop cellulitis - portal of entry small breaks in the skin [2] Atrophie blanche Located on the or foot Ivory white lesions, atrophic plaques Caused by scarring from previous injuries Ulcerations in of atrophie blanche tend to be exquisitely painful [2] Woody fibrosis deposits of fibrin in the deep dermis and fat results in a woody induration of the gaiter area (lower 1/3 of calf) of the leg peri-wound skin is often hardened and indurated, may be thickened [2]
undertaken to rule out etiologies (i.e. arterial) Exudate: moderate to heavy Infection: less common but chronic venous ulcers are prone to biofilms, induration, cellulitis, inflamed, tender blisters Surrounding Skin: Venous dermatitis, hemosiderosis lipodermatosclerosis; atrophy blanche Temperature: normal; warm to touch Edema: pitting or non-pitting; may worsen with prolonged standing or sitting from legs being in a dependent position Scarring: from previous ulcers, ankle flare, tinea pedis (athlete’s foot) Usually normal unless infection present Undermining: may be present Exudate: minimal Infection: frequent (signs may be subtle) Cellulitis, necrosis, eschar, gangrene may be present Surrounding Skin: Pale or blue feet, pallor on elevation, dependant rubor taut, thin, dry Hair loss over lower extremities Atrophy of subcutaneous tissue Edema: atypical Temperature: decreased/cold Nails: Dystrophic Infection: can have signs and symptoms of both venous and arterial disease Edema: variable Nails: Thickened toenails Location Ulceration is usually on the medial leg superior to malleolus in gaiter region but can be on lateral aspect as well or may encircle the entire ankle or leg Ulcers occurring above the or on the foot likely have other origins, but may be caused by trauma in a leg with existing venous insufficiency Areas exposed to pressure or repetitive trauma, or rubbing of footwear Lateral malleolus Mid tibial Phalangeal heads Toe tips or web spaces Same as venous or ulcer may be circumferential Pain Described as throbbing, sharp, itchy, sore, tender, heaviness Worsens with prolonged dependency. Some relief on elevation of limb. Pain is increased with elevation of limb. Pain may also be incurred with walking. This is usually due to the presence of intermittent claudication which will be relieved with 10 minutes of rest Pain with elevation Intermittent claudication (early) Night time rest pain (late disease)
May have a demarcation line of pale skin against the darker red. Clear serous or yellow exudate will “pour” out of the small openings, saturating the dressings quickly May have small blisters or large bullae unrelated to venous disease Rapid increase of edema up the lower leg… often starts at the foot but can start in the calf Raised, swollen, tight shiny or glossy skin with a stretche d appearance Skin is hot to Venous stasis dermatitis; eczema or psoriasis Shingles or chickenpox Severe acne Any trauma to the leg Leg ulceration White ethnicity Insect, spider or animal bites Immuno-suppression Foreign objects in the skin (e.g. orthotic pins) Open wounds or ulcerations Suggested Investigations: High WBC, increased ESR and C-reactive protein. Blood culture usually negative; swabs C&S usually negative unless necrotic tissue is swabbed (which is inappropriate) Management of Lower Leg Cellulitis Swabs for c&s not usually helpful if cellulitis is dry; if wet then should be done using LEVINE semi-quantitatitve method Levine Method for obtaining C&S laboratory swab 22 Cleanse wound thoroughly swab on granulation tissue enough pressure to extract fluid Turn swab 360 degrees on fluid (avoid slough or debris) swab in transport medium Mark line of demarcation on leg distally and proximally with soft-tip indelible marker (not pen) helps caregivers and patient to visualize if the infection spreads beyond the point of first assessment High compression, especially elastic systems, may be too painful to tolerate until the infection starts to respond to the antibiotic therapy. Do not stop compression entirely, because the edema will increase as a result of the cellulitis. May use appropriate lower mmHg compression such as two layers of tubular support bandage (e.g. Tubigrip) Leg elevation is important Treat any co-existing conditions such as venous ulcer, venous dermatitis or tinea pedis in addition to the systemic antibiotics In some individuals, discomfort can be soothed using a compress of Burosol solution or Burrow’s solution x 15-20 minutes available from some compounding pharmacies
Situation Suggested antibiotics If allergic to penicillin Comments Non-purulent Skin/Soft Tissue Infection (i.e. erysipelas, cellulitis, necrotizing infections) MILD: Oral treatment Penicillin VK Amoxicillin Cephalexin Cloxacillin Clindamycin MODERATE: IV treatment Penicillin G Cefazolin or ceftriaxone Clindamycin SEVERE: Surgical vs. empiric treatment Surgical Vancomycin + Piperacilin/tazobactam Clindamycin Or Vancomycin Treat for about 10 to 14 days or until signs of inflammation have resolved Purulent Skin/Soft Tissue Infection (i.e.iImpetigo, ecthyma, furuncle, carbuncle, abscess) MILD: Incision and drainage MODERATE: Incision & drainage and culture & sensitivity , plus empiric or defined treatment Doxycycline Cephalexin Cloxacillin SEVERE: Incision & drainage and culture & sensitivity, plus empiric or defined treatment Vancomycin Linezolid Cefazolin Clindamycin Clindamycin Or Vancomycin Or Linezolid Table 6: Per Dr. Stephan Landis Guelph 2015 Venous Dermatitis: Symptoms, Prevention and Treatment
Epithelializing Wound Granulating Wound, Decreasing in Surface Area in 3-4 Weeks* Clean Granulating Wound NOT Decreasing in Size 20-30% in 3-4 Necrotic Healable Wound (Debridement is Appropriate) Necrotic Wound (Debridement is NOT Appropriate) Irrigate with < 7 PSI pressure, or pour solution over the wound bed. Use at 100cc’s of solution, at room or body temperature. Cleanse the periwound skin of debris, exudates. No antimicrobial solutions. Irrigate with < 7 PSI pressure, or pour solution over the bed. Use at least 100cc’s of solution, at room or body temperature. Cleanse the periwound skin of debris, exudates. No antimicrobial solutions. Irrigate with 7-15 PSI pressure. Use at least 150cc’s of solution, at room or body temperature. Cleanse the periwound skin of debris, exudates. *Granulating wounds not decreasing in size may have a localized infection. Irrigate with 7-15 PSI pressure. Use at least 150cc’s of solution, at room or body temperature. Cleanse the periwound skin of debris, exudates. Do not irrigate or cleanse the wound itself (the intent is to allow the necrotic tissue to dry out and stabilize). If there is exudate present on the periwound skin, gently cleanse it and pat dry. Topical application of proviodine-iodine solution or Chlorhexadine to the wound surface is appropriate, i.e. paint with Proviodine. Malignant Wounds Wound with Debris or Contamination/ Superficial & Partial Thickness Burn Wound with Debris or Contamination/ Superficial & Partial Thickness Burn * Localized And/Or Spreading Infection Maintenance Wounds
Irrigate with 7-15 PSI pressure, if tolerated. Reduce pressure as needed to minimize pain and damage to friable tumor tissue. Use at least 150cc’s of solution, at room or body temperature. Cleanse the periwound skin of debris, exudates. Foul odor indicates presence of anaerobes - use an antimicrobial solution, and/or topical Metronidazole. Irrigate with 7-15 PSI pressure. Use at least 150cc’s of solution, at room or body temperature. Cleanse the periwound skin of debris, exudates. May cleanse small burns with lukewarm tap water and mild soap. Irrigate into tunneled/undermined area using a 5Fr catheter or with a 30cc syringe. Use at least 150cc’s of solution, at room or body temperature. Irrigate until returns are clear. Gently palpate over undermined or tunneled areas to express any irrigation solution that is retained. Do not force irrigation when resistance is detected. Cleanse the periwound skin of debris, exudates. Irrigate with 7-15 PSI pressure. Use at least 150cc’s of antimicrobial solution, at room or body temperature. Cleanse the periwound skin of debris, exudates. Two week challenge: May use a 10 – 14 day cleansing regime with an antimicrobial solution to address bacterial burden. Cleansing will be dependent on characteristics of wound bed and goal of treatment. If goal is to prevent wound from deteriorating, cleanse as per a Necrotic Wound. NOTE: Normal saline and sterile water do NOT contain preservatives and must be discarded 48 hours after opening
Or Composite [2-3+] +/- Film [1+] (max 7 days) Or Gauze sealed by Film [1+] (for daily changes ONLY) Foam [1-3+] (max 7 days) Or Composite [2-3+] (max 7 days) Or Gauze +/- Film seal [1+] (for daily changes ONLY) Foam [1-3+] (max 7 days) Or Composite [2-3+] (max 7 days) Or Gauze +/- Film seal [1+] (for daily changes ONLY) Composite [2-3+] (max 7 days) * Only debride healable wounds. ** If antimicrobial effect is required, consider topical antiseptic cleansers, i.e. chlorhexadine 2% or 4% (for pseudomonas – must soak x 5 min. minimum), povidone-iodine, or ¼ strength acetic acid (for pseudomonas only – must soak x 5 min. minimum). *** If antimicrobial effect is required, consider topical antimicrobial dressings, i.e. silver compounds, iodine compounds, chlorhexadine derivatives, honey, or gentian violet and methylene blue. **** For stalled granulating or epithelializing wounds consider cadexomer iodine or pocidone iodine to initiate acute inflammation or calcium alginate or protease inhibitor dressings to address chronic inflammation. ALSO, may consider pain controlling dressings for painful exudating wounds, biologic dressings for stalled granulating +/- epithelializing wounds in the absence of infection or large drainage, charcoal dressings for odor control (once the cause of the odor has been investigated and treated if able, and adjunctive therapies as indicated. Disclaimer: The information herein is for general informational purposes only and is not intended, nor should it be considered, as a substitute for professional medical advice. Always seek the advice of the attending physician or other qualified healthcare provider regarding a medical condition or treatment. Dressing selection cannot take place in isolation – a holistic patient assessment is MANDATORY.
Wound Appearance Description Eschar Primarily Slough, Granulation/Slough, or Fibrin Wounds Granulation Exudate Level None → Moderate Small → Large Small Large Depth Unknown Partial → Full Thickness Partial Full Thickness Treatment Objective Stabilize/dry necrotic tissue, prevent extension/infection, manage odor**/pain, protect Absorb/dry, fill dead space, prevent extension/infection, manage odor**/pain, protect Absorb/dry, fill dead space, prevent extension/infection, manage odor**/pain, protect Cleansing (min. 100 mL of room/body temperature solution) ** Cleanse exudate from periwound skin. Paint wound with Proviodine or Chlorhexadine 2%. Pat or air dry. POUR Proviodine or Chlorhexadine 2% solution (min. 100cc). Pat or air dry. POUR Proviodine or Chlorhexadine 2% solution (min. 100cc). Pat or air dry.