Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice

Abstract

Introduction It is well documented that the prevalence of venous leg ulcers (VLUs) is increasing, coinciding with an ageing population. Accurate global prevalence of VLUs is difficult to estimate due to the range of methodologies used in studies and accuracy of reporting. (1) Venous ulceration is the most common type of leg ulceration and a significant clinical problem, affecting approximately 1% of the population and 3% of people over 80 years of age (2) in westernised countries. Moreover, the global prevalence of VLUs is predicted to escalate dramatically, as people are living longer, often with multiple comorbidities. Recent figures on the prevalence of VLUs are based on a small number of studies, conducted in Western countries, and the evidence is weak. However, it is estimated that 93% of VLUs will heal in 12 months, and 7% remain unhealed after five years. (3) Furthermore, the recurrence rate within 3 months after wound closure is as high as 70%. (4) (-6) Thus, cost-effective adjunct evidence-based treatment strategies and services are needed to help prevent these ulcers, facilitate healing when they occur and prevent recurrence. The impact of a VLU represents social, personal, financial and psychological costs on the individual and further economic drain on the health-care system. This brings the challenge of providing a standardised leg ulcer service which delivers evidence-based treatment for the patient and their ulcer. It is recognised there are variations in practice and barriers preventing the implementation of best practice. There are patients not receiving appropriate and timely treatment in the initial development of VLUs, effective management of their VLU and preventing recurrence once the VLU has healed. Health-care professionals (HCPs) and organisations must have confidence in the development process of clinical practice guidelines and have ownership of these guidelines to ensure those of the highest quality guide their practice. These systematic judgments can assist in policy development, and decision making, improve communication, reduce errors and improve patient outcomes. There is an abundance of studies and guidelines that are available and regularly updated, however, there is still variation in the quality of the services offered to patients with a VLU. There are also variations in the evidence and some recommendations contradict each other, which can cause confusion and be a barrier to implementation. (7) The difference in health-care organisational structures, management support and the responsibility of VLU management can vary in different countries, often causing confusion and a barrier to seeking treatment. These factors further complicate the guideline implementation process, which is generally known to be a challenge with many diseases. (8).

ABPI reporting and compression recommendations in global clinical practice guidelines on venous leg ulcer management: A scoping review

“…Prolonged high pressure leads to low‐level chronic inflammation in the surrounding tissues and precipitates ulcer formation. CVI affects 2 people per 1000 of the general population in Australia, and of those, 20 per 1000 will develop an active ulcer . One in three individuals with CVI experience more than 10 episodes of ulceration in their lives, commonly with protracted healing and recurrence because of underlying pathophysiology .…”

Authors’ own method of diathermic thermal ablation of venous perforators – surgery with protective tumescence

“…Even if their clinical meaning is still under debate [17][18][19], their closure in patients presenting with severe venous insufficiency, such as class C5 and C6 according to the CEAP classification, significantly contributes to better results of treatment [20][21][22][23][24][25][26][27][28]. Incompetence of perforating veins can be of primary or secondary nature.…”

Dressings for venous leg ulcers

“…Overall, high quality evidence of effectiveness from well conducted, large, randomised controlled trials is lacking 16. This may in part be due to dressings being classed as medical devices, which require less evidence for approval than medicines 17.…”

“…This may in part be due to dressings being classed as medical devices, which require less evidence for approval than medicines 17. Problems with previously conducted trials on dressings for venous leg ulcers have included small sample sizes, small ulcer sizes, and uncomplicated patients (that is, no comorbidities, no concurrent wound infection) 16. Furthermore, using “healed wounds” as the primary outcome measure may be an unrealistic target in the context of a time-limited study for the range of venous leg ulcers seen in clinical practice.…”

“…About 1% of the adult population in Westernised countries are affected by venous ulcers on the leg or foot 2. The prevalence increases with age to 1.7% in people over 65 years old 3.…”