Treatment for venous stasis ulcers is targeted at controlling lower extremity edema. Compression dressings create an external pressure which acts from the intravascular pressure to push plasma back into the vascular system and also to prevent blood from pooling in the lower extremity. Options include a multilayer, zinc paste dressing bandage (the Unna boot), short stretch compression stockings and elastic bandages. There isn't any proven benefit of one over another; nevertheless the Unna boot should only be used in patients with good hygiene and minimal wound exudate.
Compression stockings in many cases are difficult to get on, specifically for an elderly, arthritic patient. When dressing an extremity with the Unna boot, it is important to remember to wrap from distal to proximal and to avoid wrapping so tightly that the arterial flow is occluded. If using compression stockings, options include stockings graded from 20 mm Hg to more than 60 mm Hg depending on the harshness of disease.
Due to the probability of multifactorial disease, you should eliminate an arterial contribution towards the chronic wound before applying a compression dressing. The individual also needs to be encouraged to keep their affected extremities out of the dependent position while resting to further encourage forward flow of blood and edema fluid. Keeping vascular wounds moist and clean is extremely important. As a result, saline dressing changes would be the most cost effective choice but should be done twice a day to keep the moist environment.
A hydrogel can be used with dressings that is going to be changed less often. Vacuum-assisted therapy (VAC) has become being used for vascular wounds with greater success, especially in larger wounds. Whirlpool treatment can also be coupled with dressing changes. Many patients find the water soothing, especially in painful venous ulcers.
The surgical method of venous disease has been met with little success and it is often limited to debridement of necrotic wounds and skin grafting. There's been little proven benefit to the restoration or replacing deep veins or their valves and ligation of veins to prevent retrograde blood circulation continues to be equally unsuccessful.
If a healthy wound bed can be established, autologous split-thickness skin grafts will probably take. Often, in a healthy wound bed, skin grafting then tight wrapping is used in the hopes that there's enough oxygen perfusing the top level to permit the skin graft to consider. Allogenic skin grafts such as Apligraf (Novartis, East Hanover, NJ) are eventually rejected, but provide a "biologic dressing" to prevent bacterial growth and help promote cell migration and speed healing rates.
Autologous skin equivalents, cultured from a donor sight, are expensive and time consuming to grow, but they are another option. Should more definitive closure of these wounds be necessary, with adequate arterial blood circulation, a number of rotational and free flap surgical techniques are available. These range from rotational skin flaps, to local myocutaneous flaps (gastrocnemius flaps), to free tissue transfers (radial forearm flap). Pharmacologic options range from the use of pentoxifylline, a drug considered to decrease excessive white blood cell activity and also to increase oxygen delivery to tissue. Diuretics should be thought to help alleviate edema.
Generally speaking, antibiotics for vascular wounds should be reserved for cases where systemic involvement is suspected. Wound cultures are of little value in that they only sample superficial bacteria which are often simply skin contaminates. The choice to use antibiotics should be guided by culture and sensitivity is a result of deep tissue biopsies. In the setting of suspected osteomyelitis, a radiographic workup could be pursued with plane films then bone scan if necessary.
When ruling out osteomyelitis, you should remember that X-rays often lag behind disease progression by two weeks. More recently, MRI, and specifically those using gadolinium, have been used in the workup for osteomyelitis. The definitive procedure is really a bone biopsy and culture with a six-week course of antibiotics following positive culture results.
Unlike wounds caused by venous disease, those with an arterial origin are often managed surgically. In addition to debridement of the ulcer, a revascularization bypass procedure should be performed. In cases of more proximal, focal disease in a larger artery of the leg, intravascular approaches such as balloon dilatation (percutaneous transluminal angioplasty) and stenting can be considered.
Anticoagulation shows little benefit, but often aspirin with or with no antiplatelet agent is instituted especially in the setting of stent placement. Drugs often used include pentoxifylline, clopidogrel and cilostazol. Hyperbaric oxygen has shown to be of benefit in chronic ischemic wounds and it is often used like a limb salvage technique with arterial disease, or in the setting of osseomyelitis.
In patients with nonhealing wounds and arterial insufficiency that cannot be treated surgically (poor distal target vessels for bypass options, poor surgical candidate, etc.), recent data suggest that pneumatic compression stockings that deliver retrograde sequential pressure at 120 mm Hg can improve popliteal and distal arterial flow and improve blood delivery to distal tissue.
For embolic disease, rapid institution of therapy is essential. The individual should be kept warm and also the affected limb made dependent. Full heparin anticoagulation should be started immediately and early consideration for thrombolytic agents or embolectomy is appropriate.
Initial treatment for diabetic wounds should be aimed at eliminating pressure at the wound site. Total contact casting for any diabetic foot ulcer is extremely effective. This ensures that when the extremity meets a hard surface such as the floor, pressure is distributed across the entire foot. An alternative choice may be the orthopedic shoe. It serves a similar purpose but is definitely removed for wound care and daily cleaning. Finally, the individual should be encouraged to stay away from the foot as much as you possibly can, preferably relying on the use of crutches, or wheelchair for as brief a period as is essential to allow wound healing.
Together with foot care, aggressive surgical wound debridement is a crucial part of the healing process of diabetic wounds. Devitalized tissue that can behave as a site for bacterial growth and as a barrier towards the migration of new granulation tissue should be excised. Although they are costly and little benefit has been shown in clinical trials, enzymatic debridement dressings are often included in institutional wound care protocols.
Diabetic wounds contain the distinction of being the first class of wounds shown to take advantage of growth factor therapy. Topical recombinant platelet derived growth factor BB (becaplermin) and granulocyte-colony stimulating factor have both been proven to become beneficial in randomized control trials. Synthetic skin substitutes using neonatal dermal fibroblasts and Apligraf (Novartis) in many cases are used and, as is the situation in venous wounds, may help promote cellular infiltration. Lastly, strict glucose control is of utmost importance in promoting a more effective healing process.
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