About half a million Australians live with a chronic wound, but most can be resolved when managed according to the standard of care, says emergency physician Dr Iestyn Lewis, medical lead for Royal Hobart Hospital’s wound clinic.

He describes a step-by-step approach for treating ulcers, stressing that compression therapy is usually key to a successful outcome.

Step 1: Assessment

First, gather information about the wound (e.g. when/how it happened, has it happened before?) and the patient’s general medical history. Look particularly for signs of arterial disease, malignancy or “weird infection,” Dr Lewis says.

“And going forward, if the wound doesn’t do what I expect it to do, I biopsy them, both for histology and for microbiology.”

It’s also important to do a vascular assessment. “The easiest thing for GPs to do is get an arterial duplex ultrasound. And you combine that with your clinical examination,” he says.

“What’s the capillary refill like? Do they have warm limbs? Most of your elderly patients, you probably can’t feel their pulses. But if you can feel their pulses, they’ve probably got good circulation.”

“The other thing you can do as a bedside test is an ankle brachial pressure index,” he adds. “That’s best done with a manual blood pressure cuff and a small Doppler ultrasound.”

As a general rule, an ABPI result below 0.8 suggests some degree of arterial insufficiency and patients should be reviewed by a vascular surgeon, Dr Lewis says.

“A result between 0.8-1.3 is usually safe for compression. Above 1.3 means the vessels are incompressible, often due to calcification or oedema, but this is best investigated with an arterial ultrasound.”

Step 2: Pain management

Despite what textbooks say, venous leg ulcers can cause pain, which is often neuropathic in nature (e.g. burning, stabbing, electric shocks). “And until that pain is managed, you’re not going to be able to do any significant treatment.”

Neuropathic pain medications can work quite well, he says. “If it’s mostly pain at night, I use things like Endep. If the pain is through the day, I often put them on a dose of Lyrica and I would expect to titrate that up. And as the wound heals, I generally get almost all my patients off the neuropathic pain meds, but they enable me to get my patients into compression.”

Step 3: Treat the wound

He suggests first cleaning the legs with a soap-free wash. Next, cover the wound in topical local anaesthetic and leave it for 20 minutes.

“Then I do a sharp debridement of the wound. These wounds develop a lot of slough, a lot of biofilm, a lot of dressing products. And removing that debris is going to give the wound a better chance of healing.”

He uses a disposable metal curette to do this, noting nursing teams can use metal forceps or a wound debridement pad, which cost about $15 each and look like a dishwashing cloth.

Step 4: Apply a dressing

Choose an anti-microbial, non-adherent dressing that will effectively manage exudate, Dr Lewis advises.

“We don’t want the wound too dry; we don’t want it too wet. We have to find that Goldilocks window where we’ve got moist wound healing, but a lot of the excess moisture is locked away, particularly if we then apply compression and essentially wring that wound out.”

Step 5: Compression

This step is critical, Dr Lewis stresses. “If you want to heal a difficult lower leg wound, you need to get the patient into some kind of compression garment.”

While GPs often worry compression could cause limb ischemia, this fear is usually unfounded, he says, noting the vast majority of ulcers are venous and oedema related. “They’re very unlikely to be due to arterial insufficiency.”

Compression can even be applied in patients with 50-75% arterial stenosis on duplex ultrasound provided you’re happy with other features, he says.

Moreover, ischaemia causes pain, so unless patients cannot feel pain (e.g. due to paraesthesia) or do anything about it (e.g. ask for help) then it is usually safe to apply compression, he adds.

How much compression should you use?

“Some compression is better than no compression,” Dr Lewis says, noting there are many different garments and systems you can start with.

These include TED stockings, which provide approximately 10 mm Hg compression and may be suitable for frail patients with venous leg ulcers.

Tubular products (like those by Sutherland Medical) can provide compression of about 20 to 25 mm Hg—the amount Dr Lewis aims for in most patients. “And that can be achieved with three layers of tubular form of differing lengths or their graduated, shaped tubular form. It doesn’t last that long, but it’s a good way to introduce somebody.”

Most patients will ultimately need compression stockings, which cost approximately $50 to $100 per pair, last four to six months, and come in three compression classes.

• Class 1: 15 to 20 mm Hg – which Dr Lewis tends to use in older patients
• Class 2: 20 to 30 mm Hg – which he uses in younger patients
• Class 3: above 30 mm Hg – which he uses rarely uses, “and I have difficulty getting those on myself.”

Patients can buy compression stockings on the internet or through a chemist and may need a doctor’s prescription.

Patients with big ulcers usually need compression bandaging, he adds, noting he prefers two-layer cohesive bandaging.

“The one we use is called Coban 2 or Coban 2 Light. I put most people into the light version first and then increase up to the full Coban.”

This needs to be applied by a healthcare professional and costs patients about $50 per application.

Another option, known as compression wrap, costs about $300 to $400 for a foot and lower calf application. “But we can basically get a year out of that if patients are careful with it. If you’re looking at what would otherwise be a weekly or twice weekly bandage change at $50 a go, then compression wrap becomes very cost effective over a year.”

Compression wrap can also be loosened or removed and reapplied, he says. “Not that I want them to do that, but it adds a great deal of flexibility. And almost anyone can put it on with about two minutes on a YouTube video.”

He suggests GPs write a compression plan considering:

• What will work best for the patient
• Which products are available
• The skills of your local nursing team

“The community nursing team ideally execute that plan and give us feedback. They’re going to need the go ahead from the medical practitioner to do that. And we see the patient somewhere between six to 12 weeks later to review the plan,” he says.

Patients with venous leg ulcers should know they’ll need to be in compression stockings indefinitely, he adds.

“That doesn’t mean they necessarily have to wear it every day. But they should be wearing them more often than not, even once they’re healed.”

What about leg elevation?

It’s helpful for patients with venous ulcers to elevate their legs while sitting, but movement is important, too, Dr Lewis stresses.

“Walking is good. If they’ve got good ankle mobility, the muscle pump is very good at reducing oedema. The worst thing you can do is sit or stand for prolonged periods of time.”

More information

Wounds Australia has a flow chart for managing venous leg ulcers.

Key takeaways:

• Most leg ulcers can be resolved with appropriate management, which usually includes compression therapy to manage oedema.
• Start by taking a history and assessing the wound, looking for signs of arterial disease, malignancy or unusual infection.
• Conduct a vascular assessment e.g. an arterial duplex ultrasound combined with clinical assessment. Ankle brachial pressure index can be a useful bedside test.
• Many chronic wounds are associated with neuropathic pain which needs to be treated.
• Clean the legs with soap-free wash, cover the wound in topical local anaesthetic and leave for 20 minutes, then do a sharp debridement to remove wound debris.
• Apply an anti-microbial, non-adherent dressing that will effectively manage exudate.
• Develop a compression plan for the community nursing team to follow and review the patient regularly.
• Compression is unlikely to cause limb ischemia, and it can even be applied in patients with 50-75% arterial stenosis on duplex ultrasound if you’re happy with other features.