The underlying pathophysiology of chronic venous insufficiency is complex and involves many factors. Studies have shown that average venous ulcers may need 6-12 months for complete healing with an anticipated recurrence rate exceeding 2/3 cases in 5 years. These numbers reflect the magnitude of the problem and mandate deploying all efforts to stop progression of the disease. Our group has found the following 10 tips have significantly improved our healing rates.
1. First, rule out any associated arterial, immunologic, endocrine, or other systemic causes for leg/foot ulceration.
2. Be aggressive to stop progression of the disease (fight CEAP 6): any local tenderness at the site of discolored skin at the gaiter area for venous ulcers should initiate a prompt reflux study to evaluate for incompetent perforators.
3. Venous ulcers are associated with an incompetent perforator within 2 cm of the ulcer area.
4. Recurrent venous ulcers at the same location may be associated with venous outflow obstruction, (May-Thurner syndrome is an underestimated pathology) which affects mainly the left leg.
5. When performing iliac vein venograms, make liberal use of intravascular ultrasound.
6. Exudative venous ulcers need multilayer compression dressings and appropriate antibiotics if infection exists.
7. Pentoxifylline (Trental) 800 mg, 3 times daily.
8. Frequent debridement and frequent objective evaluation for ulcer area with each office visit.
9. Bi-layered living cell treatment (Apligraf?) to promote healing.
10. Office/clinic visit every 3 months after complete healing (CEAP 5) and further testing as needed.
Dr. Mousa is an associate professor at the Department of Surgery, West Virginia University, Morgantown.