1. Management of Venous Ulcers Ms C Martin

2. Definition Chronic Venous Ulcer Open lesion between the knee and the ankle joint Remains unhealed for at least 4 weeks Occurs in the presence of venous disease

3. Assessment Varicose veins Haemosiderin Lipodermatosclerosis Atrophie blanche Oedema Dermatitis/eczema/Marjolin’s Joint mobility – calf muscle pump Arterial ABPI over 0.8 - compression therapy is safe with ABPI under 0.8 - should have referral and cardiovascular risk factor modification

4. Assessment Varicose veins Haemosiderin Lipodermatosclerosis Atrophie blanche Oedema Dermatitis/eczema/Marjolin’s Joint mobility – calf muscle pump Arterial ABPI over 0.8 - compression therapy is safe with ABPI under 0.8 - should have referral and cardiovascular risk factor modification

5. Assessment Varicose veins Haemosiderin Lipodermatosclerosis Atrophie blanche Oedema Dermatitis/eczema/Marjolin’s Joint mobility – calf muscle pump Arterial ABPI over 0.8 - compression therapy is safe with ABPI under 0.8 - should have referral and cardiovascular risk factor modification

6. Assessment Varicose veins Haemosiderin Lipodermatosclerosis Atrophie blanche Oedema Dermatitis/eczema/Marjolin’s Joint mobility – calf muscle pump Arterial ABPI over 0.8 - compression therapy is safe with ABPI under 0.8 - should have referral and cardiovascular risk factor modification

7. Investigations Duplex - arterial and venous

8. Investigations Duplex - arterial and venous Bacteriology Swabs Only with clinical signs - cellulitis, pain, malodour, increased exudate. Colonisation does not delay healing

9. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Simple non-adherent dressings are recommended for ulcers. Systematic review of 42 studies comparing - NA, alginate, hyrdocolloids, hydrogels, foams – no difference in healing when applied under multilayer bandages (ref 45). NA Ultra GranuflexDuoDerm

10. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Cochrane Review Silver vs NA – no difference Silver dressings not recommended in the routine treatment

11. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Systemic antibiotics should not be used unless there is evidence of clinical infection. Placebo controlled studies suggest increased bacterial resistance with antibiotic usage.

12. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Aspirin insufficient evidence Mesoglycan insufficient evidence Zinc insufficient evidence Pentoxifylline – 400mg tid should be considered improves healing interaction with NSAIDs

13. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Tap water vs sterile water

14. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Use a scalpel

15. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting

16. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Cochrane Review 19 trials – no benefit Honey dressing are not recommended in the routine treatment of patients with venous leg ulcers.

17. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Compression Cochrane review 7 RCTs comparing compression versus no compression – compression increases ulcer healing rates (Ref 51) Caution ABPI < 0.8, DM, neuropathic Compression Level Highest that maintains compliance. Reassess within 24-48hrs of application

18. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Multilayer Compression Layer Kit Wound contact dressing (NA, Tubinet) Layer 1 subcompression wadding bandag (soffban) Layer 2 support bandage Layer 3 compression bandage (K-Plus) Layer 4 cohesive compressive bandage (Coban) Light Compression 3 Layers Profore or K-Plus = 27 mmHG at the ankle High Compression 4 Layers K-Plus + Coban = 40 mmHG at the ankle

19. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Below knee graduated compression hosiery is recommended to prevent recurrence of venous leg ulcers in patients where leg ulcer healing has been achieved. Strongest compression which they can tolerate and apply (dexterity). Compression should be worn indefinite during the day.

20. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Compression Class British (1°)European(2°) Class 114-17mmHg18-21 mmHg Class 218-24 mmHg23-32 mmHg Class 325-35 mmHg34-46 mmHg Class 4not available49-70 mmHg Class 4(s) not available60-90 mmHg Brand Activa Medi (FP10)

21. Management There is no difference in recurrence between class 3 versus class 2 stocking, however compliance is higher for class 2. There is variation in the compression afforded between different brands of class 2 and 3 stockings. Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting

22. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Skin grafting – no evidence of benefit Bioengineered Products – single layer products – insufficient evidence of benefit

23. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Patients with chronic venous leg ulcers and superficial venous reflux should be considered for superficial venous surgery to prevent recurrence. Surgery does not improve ulcer healing but does significantly reduce recurrence rates at 12 months. ESCHAR study – Lancet 2004

24. Management Dressings Silver Drugs Cleaning Debridement Larval Therapy Manuka Honey Compression Stockings Surgery Setting Healing rates are significantly increased within a specialist leg ulcer care setting (Ref 51). Costs are lower per leg healed within a specialist clinic compared to costs within a non-specialist clinic. Larger case load with specialist leg ulcer clinics are recommended as the optimal service for community treatment of venous leg ulcers.

25. Venous Ulcers – SIGN Summary Recommended in routine careNot recommended in routine care ABPI / duplexSilver Tap waterLarvae, Versajet Simple skin care emollientManuka honey, zinc Simple non-adherent dressingSkin grafting High compression 4 layer bandagingHyperbaric/electromagnetic/Ultrasound Pentoxifylline 400mg tid 6 monthsAntibiotics B-K graduated compression stocking Endovenous surgery Community specialist leg ulcer clinics Calf muscle exercise

26. Criteria for referral Non-healing ulcer – no progress in 12 weeks Suspicion of malignancy ABPI < 0.8 Diabetes mellitus Atypical ulcers

27. Vascular ulcer clinics Royal Surrey alternate weeks Farnham Hospital alternate weeks Aldershot Centre for health (weekly) Brants Bridge ulcer clinic (Bracknell)(weekly)

28. How to refer… Referral letter Fax: 01276 526516 Vascular nurses: 01276 526302

29. Do you have a leg ulcer caused by varicose veins?Do you have a leg ulcer caused by varicose veins? We are conducting a clinical study to investigate whether early treatment of the varicose veins via modern keyhole techniques can help the leg ulcer heal faster You may be eligible to participate if:  You are 18 or over  You are not pregnant  Your doctor thinks that your varicose veins require this type of treatment For more information please speak to your doctor or call Andrea Croucher on 01276 526302 Or Fax 01276 522438 Funded by the National Institute for Health Research (NIHR HTA) Programme (project number 11/129/197) Version 1.0 EVRA Recruitment Poster 06/01/2014