Editor’s Note: Windy Cole, DPM discusses why the CORE protocol is essential for venous leg ulcer (VLU) treatment and how to prevent VLU recurrence.

Venous Leg Ulcers: Why Should Clinicians Use the CORE Protocol? from HMP on Vimeo.

Transcript

Hi, I’m Dr. Windy Cole, I’m the Director of Wound Care Research at Kent State University College of Podiatric Medicine and I’m also the Global Medical Affairs Director for Natrox Wound Care.

Could you discuss how useful the CORE protocol is for VLU management?

I think the core algorithm is key. Again, keeping things simple and keeping things evidence-based, you know, we were having a discussion recently with some colleagues, standard of care unfortunately is really not standard.

And my standard of care versus, you know, someone out in rural America, their standard of care might be completely different. I think we need to work to standardize wound care in general. So, sticking by algorithms, again, that are evidence-based or important, I think the CORE algorithm is very simple, easy to adhere to, be it your first day at wound care clinic or you’ve been in practice 20 years, I think it’s something that’s easy for clinicians to really implement into their clinical routine.

When faced with a recurring VLU, what are your first steps?

Well, recurrent VLUs are very, very common.

Again, recidivism in that patient population is about 70%. You know, you always have to do a complete patient assessment and a complete wound assessment and understand what is not being controlled with the patient to cause that re-injury or that re-ulceration from occurring. And again, a lot goes back to educating the patient on the importance of compression. I personally wouldn’t want to wear compression garments every single day, especially if I’m living in a very warm and humid environment, right?

But you have to educate the patient on how important that is because unfortunately, if they don’t establish a maintenance plan and stick with that maintenance plan, they will have a recurrent wound. So, sitting down, educating the patient, discussing it with the patient, understanding what obstacles is the patient having? Are they having difficulty wearing that compression garment? Maybe there’s an alternative compression garment. Meeting the patient where they are is really important.

Author Disclosures: Dr. Windy Cole, DPM, is on the Speaker Bureau for Organogenesis & Medical Affairs for NATROX

Venous leg ulcers (VLUs) are the most common type of chronic leg wound, and can be challenging to manage.1 VLUs account for up to 90% of all chronic leg ulcers.1 Proper diagnosis and treatment planning are key to wound healing outcomes. This fact is particularly true for older adults, who have an annual VLU prevalence of 1.7%.2

Infection Risks

Billions of dollars are spent annually to treat patients with VLUs as a result of wound chronicity, recurrence, and susceptibility to microbial invasion and infection.2 With the presence of infection, many other complications can arise and present a greater danger to the patient, such as delayed healing, cellulitis, enlargement of the wound, and debilitating pain. Deep infections can also cause systemic illness.2

Delayed healing: In addition to infection, other risk factors for delayed healing in VLUs include increased wound surface area, a history of previous ulceration, the presence of venous abnormalities (particularly deep vein pathophysiology), and the lack of high compression. Decreased mobility, advanced age, and poor nutrition are also associated with delayed healing. Because the presence of VLUs can have a profound effect on patients’ everyday lives, their emotions, and their quality of life, the longer a VLU is present, the greater the impact on the patient’s psychosocial well-being will be.3

Cellulitis: Cellulitis is a specific type of infection generally caused by group A Streptococcus and Staphylococcus aureus. It frequently requires antibiotic treatment to eradicate the responsible bacteria. Often, patients must adhere to the medication regimen while getting plenty of rest for 10 to 14 days. Signs of inflammation may be observed, although they can reflect the patient’s response to the bacterial exotoxin or the infection itself.4

Wound enlargement: Wound enlargement is a common complication of chronic wounds, such as infected VLUs.2 Given that the measurement of wound surface area is a reliable indicator of prognosis and healing, the depth, width, and length of the infected ulcer are critical components of wound assessment. As wound size increases, healing often takes longer, and patients have a poorer prognosis with larger wounds.5

Pain: With non-healing leg ulcers, the wound is stuck in a “continuous inflammation cycle” that is impacted by local factors, such as infection and underlying disorders such as any peripheral vascular disease or neuropathy. The presence of any these factors can cause an immense amount of pain, which is further compounded by treatment, such as wound cleansing, debridement, and dressing changes. Pain, along with other symptoms felt by patients with an infected VLU, serves to restrict mobility and affect patients’ quality of sleep. Pain may also negatively impact all aspects of daily life and be a source of depression, anxiety, and social isolation.6

Systemic illness: Deep infections in chronic non-healing wounds can often be masked by neuropathy; however, if patients report pain or flu-like symptoms, a systemic infection may be suspected. With this diagnosis, the infected VLU must be treated aggressively through debridement and targeted antimicrobial therapy. In some extreme cases of osteomyelitis, surgery may be necessary to treat the recalcitrant infection.7 It is also important to assess for spreading of infection to include sepsis.

Infection Prevention

Preventing infection is key to successful treatment of VLUs and to obtain conditions conducive to healing. Controlling bacteria and reducing the presence of endotoxins are critical in managing chronic wounds and preventing infection. Preventing infection in patients with VLUs is a crucial strategy that is promoted through wound care best practices, including the following recommendations8:

Avoid direct contact with the wound bed.
Use single-use disposable or sterilized equipment.
Ensure proper cleaning of equipment, disposal of equipment, and disposal of soiled dressings.
Follow proper hand hygiene protocol according to policy and procedure.
Wear personal protective equipment when clinically indicated or according to policy and procedure.

Conclusion

VLUs occur in approximately 1% of the Western population, and these lesions have wound healing times of 3-12 months. During this time, quality of life is generally negatively impacted.9 Infection can often worsen a patient’s prognosis by introducing other complications. The optimal treatment modality ensures that all measures are taken to prevent infection whenever possible. This goal is crucial to improve patients’ prognoses and limit unnecessary antimicrobial use.

References

1. NHS Inform. Venous leg ulcer. National Health Service (Scotland); updated July 2019. https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails…. Accessed January 2, 2020.

2. Pugliese DJ. Infection in venous leg ulcers: considerations for optimal management in the elderly. Drugs Aging. 2016;33(2):87-96.

3. Parker CN, Finlayson KJ, Shuter PE, Edwards HE. Risk factors for delayed healing in venous leg ulcers: a review of the literature. Int J Clin Pract. 2015;69(9):967-977.

4. Davis JS, Mackrow C, Binks P, et al. A double-blind randomized controlled trial of ibuprofen compared to placebo for uncomplicated cellulitis of the upper or lower limb. Clin Microbiol Infect. 2017;23(4):242-246.

5. Vasudevan B. Venous leg ulcers: pathophysiology and classification. Indian Dermatol Online J. 2014;5(3):366-370.

6. Catanzano O, Docking R, Schofield P, Boateng J. Advanced multi-targeted composite biomaterial dressing for pain and infection control in chronic leg ulcers. Carbohydr Polym. 2017;172(15):40-48.

7. Frykberg RG, Banks J. Challenges in the treatment of chronic wounds. Adv Wound Care. 2015;4(9):560-582.

8. Minnesota Department of Health. Wound care infection prevention recommendations for long-term care facilities. 2018. https://www.health.state.mn.us/facilities/patientsafety/infectioncontro…. Accessed January 12, 2020.

9. Meulendijks AM, de Vries FMC, van Dooren AA, Schuurmans MJ, Neumann HAM. A systematic review on risk factors in developing a first-time venous leg ulcer. J Eur Acad Dermatol Venereol. 2018;33(7):1241-1248. 

Venous ulcers pose a worldwide problem that comes with potential for high recurrence rates, risk of infection, and substantial treatment costs. Health care professionals must be knowledgeable about underlying causes and pathological features. Comorbidities often associated with venous ulcers contribute to these lesions and prolong healing times, which in turn can cause further complication. Venous disease and venous hypertension are lifelong conditions requiring lifelong management. The vicious cycle of venous reflux and obstruction associated with chronic venous disease can lead to ulceration(s). Management of venous ulcers requires comprehensive wound care and compression therapy for life.

Venous ulcers are known to be complex and costly. There is an array of evidence-based treatment options available to help formulate a comprehensive treatment plan toward wound closure. Health care professionals should utilize treatment options while encompassing a holistic approach to venous ulcer management. Involving the patient and/or caregiver in developing a treatment plan will increase the chances of successful wound healing outcomes. Wound closure is the primary goal of a treatment plan; however, preventing recurrence and infection should be considered just as important.

Evidence-Based Treatment Options

Compression Therapy

Compression therapy is considered the “gold standard” of care for venous ulcers. Compression therapy goals include edema management, venous reflux improvement, and enhanced healing.1,2 Compression therapy can consist of 1 or more layers.3

Elastic: bandages that conform to the size and shape of the leg.
Inelastic: zinc oxide–impregnated gauze wraps such as an Unna boot.
Dual compression: a compression method that combines elastic and inelastic bandage use simultaneously.
Stockings or custom garments: can be knee-high, thigh-high, toes in or out. Patient preference should be considered when selecting a garment; 30mmHg to 40mmHg strength is preferred.5,6
Pneumatic compression pumps: 3 types of pumps that deliver variances of pressure gradient, inflation, and deflation cycles.4
Leg elevation: increase deep venous flow and reduce venous pressure. Legs should be elevated above heart level.4

Advanced Wound Care Dressings

Wound care professionals should determine dressing selection by wound location, size, depth, exudate amount, bioburden or biofilm, frequency of dressing change, payer source or cost, and availability.4 Many dressings are available with or without antimicrobial properties such as silver or honey. Use as clinically indicated.

Absorbent dressings: alginates, foams, and super absorbents; charcoal available for odor control
Hydrocolloid: all shapes, sizes, and thicknesses; used as primary or secondary dressings
Impregnated gauzes (low-adherence or non-stick): oil emulsion, petrolatum gauze, and bismuth gauze
Collagen matrix: with or without silver

Antimicrobials and Antiseptics

Evidence has shown that cadexomer iodine, povidone-iodine, medical-grade honey, peroxide-based preparation, and silver are among options that may improve healing of venous ulcers.7

Wound Cleansers and Surfactants

Wound cleansers, surfactants, and solutions can help remove exudate, contaminants, and foreign debris in wound bed preparation. There are rinse and no-rinse formulas.

Advanced Wound Care Therapies

Cellular and tissue-based products
Skin grafting: used as secondary therapy for ulcers when standard care fails

Medications

The following medications may be part of a comprehensive treatment strategy for patients with venous disease:

Pentoxifylline: hemorheologic agent that affects microcirculation and oxygenation4
Aspirin (acetylsalicylic acid [ASA]): inconsistent evidence concerning benefits and harms of oral ASA in treatment of venous ulcers4
Statins: vasoactive and anti-inflammatory effects4
Phlebotomics: improves venous tone and decreases capillary permeability4
Antibiotics: Systemic or topical and warranted only if infection is suspected4

Debridement Methods

Wound bed preparation has been shown to expedite healing rates. Using a debridement method can help move venous ulcers toward healing. Patients treated with sharp debridement at each physician’s office visit had significant reductions in wound size compared with those patients who didn’t.8

Biological: maggot therapy
Enzymatic: such as, collagenase ointment
Autolytic: moisture-retentive dressings such as hydrocolloid, transparent, and alginate dressings
Mechanical: wet-to-dry dressings, whirlpool, pulse lavage
Sharp debridement: using instrumentation such as a scalpel or curette (can be performed in the operating room (surgical debridement), in the clinic, or at the bedside)

Endovenous Intervention

Endovenous interventions include endovenous ablation, ligation, subfascial endoscopic perforator surgery, and sclerotherapy. Recent trials show faster healing rates of venous ulcers when early endovenous ablation to correct superficial venous reflux is performed in conjunction with compression therapy, compared with compression alone or with delayed intervention of an ulcer that has not reached wound closure after 6 months.9

Multidisciplinary Team Approach

The complexity of venous ulcer treatment warrants a team effort. It takes a multidisciplinary team approach to focus on various comorbidities and issues a patient may have. Utilizing a specialized team member will provide a comprehensive plan of care. Communication with each team member while focusing on a patient-centered approach is critical to preventing gaps in care. Working together, the team can move toward successful outcomes for their patients.

References

1. O’Donnell TF Jr., Passman MA, Marston WA, et al.; Society for Vascular Surgery; American Venous Forum. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg. 2014;60(2)(suppl):3S-59S.

2. Mauck KF, Asi N, Elraiyah TA, et al. Comparative systematic review and meta-analysis of compression modalities for the promotion of venous ulcer healing and reducing ulcer recurrence. J Vasc Surg. 2014;60(2)(suppl):71S-90S,e1-e2.

3. Hettrick H. The science of compression therapy for chronic venous insufficiency edema. J Am Col Certif Wound Spec. 2009;1(1):20-24.

4. Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Repair Regen. 2009;17(3):306-311.

5. Vandongen YK, Stacey MC. Graduated compression elastic stockings reduce lipodermatosclerosis and ulcer recurrence. Phlebology. 2000;15(1):33-37.

6. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2014;(9):CD002303.

7. O’Meara S, Al-Kurdi D, Ologun Y, et al. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 2014;(1):CD003557.

8. Bonkemeyer Millan S, Gan R, Townsend PE. Venous ulcers: diagnosis and treatment. Am Fam Physician. 2019;100(5):298-305.

9. Gohel MS, Heatley F, Liu X, et al.; EVRA Trial Investigators. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018;378(22):2105-2114.