The management of patients

with venous leg ulcers

Recommendations for
assessment, compression therapy,
cleansing, debridement, dressing,
contact sensitivity,
training/education and
quality assurance
1998

Produced by the RCN Institute,
Centre for Evidence-Based Nursing, University of York
and the School of Nursing, Midwifery and
Health Visiting, University of Manchester

RCN Members
£5.50
Non RCN Members
£7.50
ISBN 1-873853-78-5
Reorder No: 000987

0 Quality assurance 20 References of included material 21 Appendix 1: Evidence tables on leg ulcer assessment.0 Cleansing.0 The management of venous leg ulcers 13 Compression therapy 13 Pain assessment and relief 15 Prevention of recurrence 15 3. dressings and contact sensitivity 17 Cleansing 17 Debridement 17 Dressings 18 Contact sensitivity 18 4.0 Education and training in leg ulcer care 20 5.0 The assessment of patients with ulcers 5 Who should assess the patient? 5 Clinical history and inspection of the ulcer 6 Clinical investigations 9 Doppler measurement of ankle/brachial pressure index 10 Ulcer size/measurement 11 Referral criteria 12 2. Appendix 2: Effective Health Care Bulletin (Centre for Reviews and Dissemination. psychosocial implications of leg ulcer disease and training/education on leg ulcer care. debridement.Contents Notes for users of these guidelines 2 Summary of recommendations 3 1. 1997) Compression Therapy for Venous Leg Ulcers Appendix 3: Contributors to the guidelines The management of patients with venous leg ulcers Recommendations 1 .

17–19 Peterborough Road. particular patient’s circumstances and wishes. despite the objectives and methods of guideline development strength of evidence grade accorded to them. a acceptable studies. as with any II Either based on a single acceptable study. Bulletin on Compression Therapy for Venous Leg Resources permitting. However. This document contains recommendation statements which were graded as follows: Disclaimer I Generally consistent finding in a majority of multiple acceptable studies. the opinion. or a clinical guideline. guideline are appended to this document. NHS This work is being undertaken as part of a national CRD and updated sections of an original systematic sentinel audit project funded by the NHS Executive. clinical The evidence grade alerts the reader to the type of experience of the practitioner and knowledge of evidence supporting each statement. Technical report: guideline and are not regarded as optional. Eli Lily opinion and are thought to reflect current good National Clinical Audit Centre. of Physicians. it is envisaged that the Ulcers that summarise the evidence base of the guideline will be updated 2-yearly. limitation of any guideline is that it simplifies clinical decision-making processes and III Limited scientific evidence which does not meet recommendations (Shiffer 1997). All of the practice guidelines. Compression Therapy for Venous Leg Ulcers. for further information on the methods used to develop the guideline and its evidence base. Guideline users should be mindful that. grading should not be interpreted as indicative of The reader is referred to the document: Clinical the strength of recommendation. strong evidence base were informed by expert Centre for Evidence Based Nursing. made by the practitioner in the light of available This includes published or unpublished expert resources. The Technical Report can be obtained from RCN Publishing. this more recent research findings. policies and protocols. Recommendations without a in partnership with the Royal College of Nursing. piloted in 1999 and will be available in 2000. the Royal College clinical practice. Clearly. local services. The management of patients recommendations are equally strongly endorsed with venous leg ulcers. (adapted from Waddell et al 1996) available personnel and equipment. review (Cullum 1994). Updating of the guideline Evidence tables and the Effective Health Care The guideline was completed in mid-1998. Harrow HA1 2AY. Decisions to all the criteria of acceptable studies or absence adopt any particular recommendation must be of directly applicable studies of good quality. 2 The management of patients with venous leg ulcers Recommendations . recommendations may not be weak or inconsistent finding in multiple appropriate for use in all circumstances. Notes for users of these guidelines Evidence base Audit The evidence base for these recommendations Audit criteria based on this guideline are being came from the Effective Health Care Bulletin. Nursing Standard House. The Royal College of General Practitioners and the Tissue Viability Society.

any patient rapid deterioration of the ulcer. hyperkeratotic skin. increased pain. cigarette smoking. ulcers of non-venous recurrent leg ulcer and should be ongoing thereafter aetiology. encouragement of mobility and arterial disease: ‘punched out’ appearance. should be the first line of treatment for uncomplicated venous leg ulcers (ABPI must be ≥ 0. suspected malignancy. Dressing technique should be clean and aimed maceration. gangrenous toes Cleansing. site Use of compression stockings reduces venous ulcer recurrence rates II of ulcer and of any previous ulcers. proven deep vein cellulitis. process and outcome The management of patients with venous leg ulcers Recommendations 3 . dependent rubour. pale or blue feet. purulent exudate. patients may present with a combination of the features described above The compression system should be applied by a trained practitioner II The person conducting the assessment should be aware that III Health professionals should regularly monitor whether patients II ulcers may be arterial. surgery/fractures to leg. discourage self-treatment with over-the-counter preparations. skin care. signs of irritation and scratching. ankle flare. experience pain associated with venous leg ulcers and formulate should record any unusual appearance and if present refer the an individual management plan. purulence. family history of venous disease. which may be indicative of venous disease: III newly diagnosed diabetes mellitus. autolytic. which may consist of patient for specialist medical assessment compression therapy. stretch regimens). time free of include the following. signs of contact dermatitis. with warmed tap water or saline is The presence of oedema. diabetic. cellulitis. exercise. necrosis. Following patch testing. healed ulcers with a view to venous surgery. chemical or enzymatic debridement routine monitoring thereafter Dressings must be simple. increased ABPI. which may be indicative of non-venous III Management of venous leg ulcers aetiology: family history of non-venous aetiology. eczema. varicose veins. there is a sudden increase in size of ulcer. there is a sudden increase in pain. which have received adequate treatment and have not improved suspected deep vein thrombosis. dressing. atrophie blanche of possible skin breakdown. low cost and acceptable I Blood pressure measurement. low adherent.Summary recommendations Strength of Evidence Strength of Evidence Assessment of leg ulcers Assessment of leg ulcers continued Assessment and clinical investigations should be undertaken by a III A formal record of ulcer size should be taken at first presentation. taut skin. time to healing in previous episodes. lifetime compression therapy. contact sensitivity mixed venous/arterial: features of venous ulcer in combination with signs of arterial impairment Cleansing of the ulcer should be kept simple: irrigation of the III ulcer. phlebitis in the affected leg. diagnostic uncertainty. leg elevation and analgesia to meet the needs of the patient Information relating to ulcer history should be recorded in a III structured format and may include: year first ulcer occurred. shiny. after 3 months. regular follow-up to monitor ABPI following to aid assessment of ulcer type: Patient education: compliance with compression hosiery. regular follow-up to monitor skin condition for Examine both legs and record the presence/absence of the III recurrence. oedema. reduced ABPI. capable of sustaining rheumatoid arthritis. degree of granulation tissue. rapid deterioration of ulcers. with adequate padding. recurring ulceration. pain management embolus Record the following. varicose avoidance of accidents or trauma to legs. I vascular disease/intermittent claudication. elevation of the affected limb when immobile poorly perfused and pale. hyperpigmentation.strict asepsis is unnecessary epithelization. arterial disease by Doppler measurement of ABPI identified allergens must be avoided and medical advice on Doppler measurement of ABPI should be done by staff who are II treatment should be sought trained to undertake this measure Doppler ultrasound to measure ABPI should also be conducted II Education/training when: an ulcer is deteriorating. Record the following. an ulcer it not fully healed by 12 Health care professionals with recognized training in leg ulcer III weeks. ischaemic rest pain compression for at least a week. and. cold legs/feet. patients present with ulcer recurrence. previous operations on venous system. weight. III usually sufficient. previous and current use of compression hosiery Clinical: venous investigation and surgery. granulation Removal of necrotic and devitalized tissue can be achieved through III and odour should be recorded at first presentation and as part of mechanical. depending on the needs of the patient: ulcers. urinalysis and Doppler III to the patient measurement of ankle: brachial pressure index (APBI) should be Health professionals should be aware that patients can become II recorded on first presentation sensitized to elements of their treatment at any time Routine bacteriological swabbing is unnecessary unless there is I Products which commonly cause skin sensitivity such as those III evidence of clinical infection such as: inflammation containing lanolin and topical antibiotics should not be used on /redness/evidence of cellulitis. where necessary. heart disease. patient is wearing care teams compression hosiery as a preventive measure. lipodermatosclerosis. foot Quality assurance colour and/or temperature of foot change. haemoptysis or history of a pulmonary foot. transient ischaemic attack. ulcers thrombosis in the affected leg. venous disease: usually shallow (usually on gaiter area of leg). rheumatoid or malignant. debridement. early self-referral at signs veins. pyrexia Patients with suspected sensitivity reactions should be referred to III All patients presenting with an ulcer should be screened for I a dermatologist for patch testing. unusual wound edges (eg rolled). diabetes mellitus. signs of at preventing cross-infection . ischaemic foot.8) In mixed venous/arterial ulcers. past treatment methods. number of previous episodes Other strategies for the prevention of recurrence may also III of ulceration. peripheral Graduated multi-layer high compression systems (including short. as part of ongoing assessment (3 monthly) Systems should be put in place to monitor standards of leg ulcer III care as measured by structure. stroke. slough. before care should cascade their knowledge and skills to local health recommencing compression therapy. eczema. III health care professional trained in leg ulcer management and at least at monthly intervals thereafter A full clinical history and physical examination should be III Specialist medical referral may be appropriate for: III conducted for a patient presenting with either their first or treatment of underlying medical problems. base of wound exercise. infected episodes of chest pain.

4 The management of patients with venous leg ulcers Recommendations .

Surveys of knowledge and reported practice were of variable Rationale quality (four cross-sectional and one before and Surveys of reported practice of leg ulcer care by after design) but gave fairly consistent results. The essential point is that the person conducting the assessment (and who is responsible for the care and treatment of the patient and the application of these recommendations) must be trained and experienced in leg ulcer care. nurses have demonstrated that knowledge often falls far short of that which is ideal (Bell 1994.1 Assessment and clinical investigations evidence-based.1. as well as lack of equipment and referral criteria (Griffey 1992. Roe et al 1993). No trials were found which assess should be undertaken by a health care and compare the reliability and accuracy of nursing professional trained in leg ulcer assessment or which compare the cost-effectiveness management of general practitioner (or other health professional) with nurse assessment of patients with leg ulcers or compare other models of assessment. Insufficient training. Consequently. Stevens et al 1997) may also contribute to variation in assessment practices by nurses. this recommendation states ‘health care professional’: referring to a nurse or a practitioner other than a nurse. Roe et al 1994) and that there is wide variation in the nursing management. district nurse and practice nurse training courses.0 The assessment of patients with leg ulcers Strength of the evidence (III) Who should assess the patient? The recommendation is consensus rather than 1. in areas of the UK (Elliott et al 1996. The management of patients with venous leg ulcers Recommendations 5 . The consensus group view is that there needs to be a commitment to make training in the assessment and management of patients with leg ulcers a mandatory part of general practitioner. including assessment of leg ulcers. There is also debate about whether leg ulcer assessment should be undertaken routinely by nurses (Cullum et al 1997). One audit found that over 80% of patients known to the district nursing services had not been assessed using Doppler ultrasound to determine ulcer aetiology prior to treatment (Stevens et al1997) and another study (Elliott et al 1996) found that 50% of district nurses used visual assessment alone to diagnose a leg ulcer. The UKCC gives little guidance on the matter of what constitutes adequate training levels for nurses involved in leg ulcer care.

stroke.3 Record the following which may be the ulcer indicative of venous disease • family history 1. Roe et al 1993. a swollen leg after surgery. observation alone is insufficient to determine the aetiology (refer to recommendations 1. There indicative of non-venous aetiology is evidence that danger occurs if arterial ulcers are • family history of non-venous aetiology not properly diagnosed and receive compression • heart disease. features described above Strength of evidence (III) This recommendation is consensus-based as there Rationale are no studies which examine patient outcomes comparing patients given or not given the benefit Patients with venous and non-venous leg ulcers of a full clinical history and physical examination. often have a readily recognized clinical syndrome comprising some of the above features and staff should be trained to recognize these. This will assist the accurate identification of aetiology. or led to long periods of ineffective and often history of a pulmonary embolus inappropriate treatment (Cornwall et al 1986.0 The assessment of patients with leg ulcers Clinical history and inspection of 1. If the practitioner is unable to conduct a physical examination.11). trauma or a period of Rationale enforced bed rest) Lack of appropriate clinical assessment of patients • surgery/fractures to the leg with limb ulceration in the community has often • episodes of chest pain. This will assist identification of both the • cigarette smoking underlying cause and any associated diseases and • rheumatoid arthritis will influence decisions about prognosis. However. pregnancy.1. Elliott Record the following which may be et al 1996. • ischaemic rest pain investigation and management. 6 The management of patients with venous leg ulcers Recommendations . they In mixed venous/arterial ulcers patients must refer the patient to an appropriately trained may present with a combination of the professional. referral. as well as • peripheral vascular disease/intermittent appropriate laboratory tests and haemodynamic claudication assessment. haemoptysis.10. It is therefore advisable that attack diagnosis of ulcers should be based on a thorough • diabetes mellitus clinical history and physical examination. transient ischaemic (Callam et al 1987b). Stevens et al 1997). which has major implications for treatment choice. 1.2 A full clinical history and physical • varicose veins (record whether or not examination should be conducted for a treated) patient presenting with either their first or • proven deep vein thrombosis in the recurrent leg ulcer and should be ongoing affected leg thereafter • phlebitis in the affected leg • suspected deep vein thrombosis (for example.

Ulcers with atypical site and appearance such as rolled edges. rheumatoid or malignant. Yang et al 1996). often over bony structures examined are not comparable. Rheumatoid ulcers These are commonly described as deep. It is needed to determine risk factors for venous disease essential to identify underlying aetiology. particularly if diabetes is poorly controlled. arterial blood supply to the lower limb. record any unusual appearance and refer the patient for specialist medical Malignant ulcers assessment* Malignancy is a rare cause of ulceration and more rarely. or non-healing ulcers with a Arterial ulcers raised ulcer bed should be referred for biopsy and Arterial leg ulcers are caused by an insufficient medical attention (Ackroyd & Young 1983. A vascular assessment is required in order to Strength of evidence (III) establish the location and extent of the occlusion and the presence of small vessel disease (Cullum This recommendation is based on expert opinion 1994). should be referred to a diabetologist or diabetic clinic. 1. there are a number whether the patient is suitable for angioplasty or of studies (mainly prevalence surveys and case major vascular surgery. epidemiological studies are (Browse et al 1988. Baldursson et al 1995. and venous ulceration so that prevention strategies Consequently. Malignant ulcers can be confused with venous ulcers and longstanding venous ulcers may become malignant (Ackroyd & Young 1983. Well- neuropathic. The management of patients with venous leg ulcers Recommendations 7 . Nelzen et al 1993). Yang et Rationale al 1996). there is prominences such as the bunion area or under the relative concordance of data on aetiological factors metatarsal heads and usually have a sloughy or and the medical criteria used to define venous. studies) which have examined the prevalence and/or clinical features of these type of ulcers. Patients with rheumatoid arthritis might also develop ulcers associated with venous disease. a consequence of chronic ulceration (Ackroyd * if there is any doubt about aetiology the patient & Young 1983. The specialised assessment will determine although as referenced above. well- demarcated and punched-out in appearance. arterial and/or venous components designed.0 The assessment of patients with leg ulcers Strength of evidence (III) Diabetic ulcers Although the methods employed and population These are usually found on the foot. prospective. resulting in Baldursson et al 1995. measurement of ABPI may be unreliable in this diabetic. should group of patients. Yang et al should be referred to the appropriate specialist 1996). non-venous and mixed aetiology ulcers are well- An ulcer in a diabetic patient may have defined (Alexander House Group 1992). necrotic appearance (Cullum & Roe 1995).4 The person conducting the assessment Specialist assessment is essential as Doppler should be aware that ulcers may be arterial.1. They are usually situated on the dorsum of the foot or calf (Lambert & McGuire 1989) and are often slow to heal. ischaemia and necrosis (Belcaro et al 1983. Carter 1973). all diabetic patients with leg ulcers can be developed (Cullum & Roe 1995).

taut skin Collection of these data in a structured format will • dependent rubor enable consideration of clinical factors that may • pale or blue feet impact on treatment and healing progress. 1. However.6 Examine both legs and record the be recorded in a structured format and may presence/absence of the following to aid include assessment of type of ulcer • year first ulcer occurred Venous disease • site of ulcer and of any previous ulcers • usually shallow ulcers (situated on the • number of previous episodes of gaiter area of the leg) ulceration • oedema • time to healing in previous episodes • eczema • time free of ulcers • ankle flare • past treatment methods • lipodermatosclerosis (both successful and unsuccessful) • varicose veins • previous operations on venous system • hyperpigmentation • previous and current use of compression • atrophie blanche hosiery Arterial disease • ulcers with a ‘punched out’ appearance • base of wound poorly perfused and pale Rationale • cold legs/feet (in a warm environment) • shiny.5 Information relating to ulcer history should 1. as well • gangrenous toes as provide baseline information on ulcer history. these signs do not construct a diagnosis per se (refer to recommendations 1. However.10.11) Strength of evidence (III) Consensus statements and literature reviews concur on well known features of these conditions (Alexander House Group 1992. All of the above are well-recognized signs respectively of chronic venous insufficiency and arterial disease (as indicated). Browse et al 1988).0 The assessment of patients with leg ulcers 1. 8 The management of patients with venous leg ulcers Recommendations . These will have the features of a venous ulcer in combination with signs of arterial Strength of evidence (III) impairment This statement is consensus based as no research was identified which examined whether a structured approach for recording ulcer history Rationale results in improved management and patient outcomes. 1. diagnosis of ulcer type should not be Mixed venous/arterial made solely on this information.

slough. weight is taken at baseline to monitor Rationale weight loss if the patient is obese and urinalysis is The condition of the ulcer and surrounding skin taken to screen for undiagnosed diabetes mellitus.10. if eczema with itching is present. If the (refer to recommendations 1. eczema. Strength of evidence (III) oedematous skin will need careful application of This recommendation is supported by consensus compression bandages (although. if there is no eczema the of ABPI is essential to rule out arterial disease surrounding intact skin can be moisturized. a topical clinical history and local protocols. rolled). odour should be recorded at first presentation and as part of routine monitoring thereafter Rationale Blood pressure is taken to monitor arterial disease. Trengove et al 1996) and most have found that ulcer healing is not influenced by the presence of bacteria. Strength of evidence (I) 1 RCT and 1 prospective study. not necessarily opinion. fragile. Ericksson et al 1984. Clinical investigations hyperkeratotic skin. Skene et al 1992. degree of granulation tissue. ulcer is odorous and sloughy frequent dressing changes may be considered.1. cellulitis. unusual wound edges urinalysis and Doppler measurement of (e. Also.9 Routine bacteriological swabbing is Strength of evidence (III) unnecessary unless there is evidence of Although the exact role that a systematic and clinical infection such as comprehensive skin inspection plays in improving • inflammation/redness/cellulitis care has not been empirically tested. epithelization. weight. purulence.7 The presence of oedema. decreased compression). there is • increased pain general expert agreement that skin inspection is a • purulent exudate fundamental part of assessment. Trengove et al 1996). Measurement steroid may be required. 1. but how this affects healing is debatable (Skene et al 1992.0 The assessment of patients with leg ulcers 1. The management of patients with venous leg ulcers Recommendations 9 . signs of irritation and APBI should be recorded on first scratching.11).8 Blood pressure measurement. • rapid deterioration of the ulcer • pyrexia Rationale Chronic leg ulcers are usually colonized by micro- organisms. presentation granulation.g. necrosis. will influence skin care and will provide baseline The need for additional blood and biochemical information for evaluating treatment outcomes. signs of 1. The influence of bacteria on ulcer healing has been examined in a number of studies (Ericksson 1984. For investigations will depend on the patient’s example. maceration. 1.

Two large studies have shown respectively that 67% and Strength of evidence (II) 37% of limbs with an ABPI of <0. The importance of making an objective aetiological diagnosis by measuring ABPI. Simon et al 1994). 10 The management of patients with venous leg ulcers Recommendations . which suggests that diagnosis pressure readings (Callam et al 1987b. Callam et al 1987b. pedal pulse palpation and a thorough clinical history and physical assessment.9 had palpable One before-after. Rationale Ray et al 1994). Patients with regarded as signs of arterial disease. Corson et al should not be solely based on the absence or 1986. Callam et al 1987b. with the consequent risk of applying controlled study. Nelzen et al 1994. One survey of surgeons found that 32% reported at least one instance of necrosis induced or aggravated by compression bandages of stockings (Callam et al 1987c). Furthermore. Sindrup et al 1987) and Doppler ultrasound can aid diagnosis in such cases. there these conditions may have deceptively high is a body of research. by staff who are trained to undertake this measure ABPI training Rationale Unless operators have undergone formal training in The importance of assessing the blood Doppler ultrasound technique.4). ABPI (Brearley et al 1992. be screened for arterial disease by Doppler measurement of ABPI. Moffatt et al 1994). Magee et al 1992. in addition to visual inspection of the ulcer. is highlighted by a number of studies (Moffatt et al 1994. Cornwall et al 1986. co-exist in the same individual (Callam 1987c. ABPI measurements supply to the leg can be unreliable (Brearly et al 1992. detection of arterial insufficiency which could result in the commencement of inappropriate and even Training should also emphasize that ABPI dangerous therapy. Fowkes et al 1988). compression to people with arterial disease (Callam et al 1987b. Absent or very weak foot pulses measurements in patients with diabetes or indicate poor peripheral blood supply and are atherosclerosis may not be reliable. However.10 All patients presenting with an ulcer should controlled study and one cohort study. Magee et al 1992. Reliability of Doppler measurements All patients should be given the benefit of Doppler can be considerably improved if operators are highly ultrasound measurement of ABPI to ensure trained (Fisher et al 1996. venous and arterial disease can and often do. 1. four cross-sectional and one foot pulses. Moffatt & O’Hare 1995). Scriven et al 1997. one 1. Dealey 1995) and such patients should be presence of pedal pulses because there is generally referred for specialist assessment (refer to poor agreement between manual palpation and recommendation 1.0 The assessment of patients with leg ulcers Strength of evidence (I) Doppler measurement of ankle/brachial pressure index (ABPI) The evidence for this recommendation is mainly from a number of cross-sectional studies.

Liskay et al • and. should be based primarily on the local expertise Sindrup et al 1987) and significant reductions in available to perform and interpret the measurement ABPI can occur over relatively short periods of time and the availability of equipment. as part of ongoing assessment may be determined by local protocols. However.0 The assessment of patients with leg ulcers 1. each time. prevent adequate comparison of the reliability of measurements obtained with the various wound measurement procedures. personnel and statistical differences in the six cross-sectional studies One cohort and two cross-sectional studies. The mindful that wound state should also be regularly regularity with which Doppler studies are repeated monitored (refer to recommendation 1. as part of ongoing assessment 1993. Scriven et al 1997. Majeske 1992). the choice of a measurement method venous disease (Callam 1987c. the practitioner should be Simon et al 1994).7).11 Doppler ultrasound to measure ABPI should Ulcer size/measurement also be conducted when • an ulcer is deteriorating 1.12 A formal record of ulcer size should be • ulcer is not fully healed by 12 weeks taken at first presentation. ideally. There was consensus agreement that sophisticated measuring devices are unnecessary in everyday clinical practice. Strength of evidence (III) Strength of evidence (II) Design. Arterial disease may develop in patients with Therefore. ABPI will also fall with age. change Buntinx et al 1996. setting. and at least at • patients present with ulcer recurrence monthly intervals thereafter • before recommencing compression therapy • patient is wearing compression hosiery as a preventive measure Rationale • there is a sudden increase in size of ulcer The literature demonstrates a variety of methods • there is a sudden increase in pain used to measure wounds which mainly focus on • foot colour and/or temperature of foot wound area rather than depth (Ahroni et al 1992. by the same practitioner reported (Nelzen et al 1994. Monitoring (3-12 months) (Simon et al 1994).1. Scriven et al 1997. Etris et al 1994. Many of the described (three monthly) measurement techniques (Johnson & Miller 1996) may be too cumbersome and invasive for everyday use in the clinical setting where rapid assessment is Rationale required and where monitoring of progress rather than accurate measurement is the priority. The management of patients with venous leg ulcers Recommendations 11 . placing a current tracing over a also had detectable arterial insufficiency have been previous tracing. Estimates of progress can be done cheaply and easily using between 13%-29% of legs with venous ulcers which serial tracings.

1. • newly diagnosed diabetes mellitus • signs of contact dermatitis (spreading Strength of evidence (III) eczema.0)* rheumatologist. mixed. One study of district nurse records • treatment of underlying medical indicated that only 35% of leg ulcer patients were problems referred at any stage for a specialist assessment and • ulcers of non-venous aetiology 7% had been examined by a vascular surgeon (rheumatoid. and have not improved after professionals within primary care were found. routine vascular referral. • ischaemic foot • infected foot • pain management * may vary according to local protocols 12 The management of patients with venous leg ulcers Recommendations .8 – diabetic ulcers for specialist advice (Roe et al 1993). • increased ABPI (for example. arterial. most of the nurses aetiology) felt that further investigation of the patients was • suspected malignancy necessary. diabetic. diabetologist or other medical • rapid deterioration of ulcers specialist. increased itch) • cellulitis Principal criteria for referral are widely agreed by • healed ulcers with a view to venous experts although no studies examining the surgery outcomes of patients with leg ulcers referred from • ulcers which have received adequate primary to secondary care or between health treatment. Another study found that only six out of • diagnostic uncertainty 146 nurses would refer patients with rheumatoid or • reduced ABPI (for example. (Lees & Lambert 1992). dermatologist. three months Trials are being established to evaluate the • recurring ulceration effectiveness of early surgery before ulcer healing.5 – urgent Local protocols will dictate if the patient is to be vascular referral)* referred to a vascular surgeon.13 Specialist medical referral may be may not be referred appropriately for specialist appropriate for assessment.0 The assessment of patients with leg ulcers Rationale Referral criteria There is some research which shows that patients 1. <0. However. <0. >1.

four-layer (Taylor et al 1998). more frequent dressing changes will be required High compression vs.8.8) Strength of evidence (I) This recommendation is based on six RCTs. the first line of treatment for uncomplicated venous leg ulcers (ABPI must be ≥ 0. capable of sustaining effective because the faster healing rates saved compression for at least a week* should be nursing time (Taylor et al 1998).6–0. large and two small trials which found more ulcers healed at 24 weeks using four-layer bandaging Strength of evidence (III) than were healed using a single layer. However. Again. for example There is reliable evidence that high compression 0.8. consensus group views and two studies (Callam et al 1987b.0 The management of venous leg ulcers Compression therapy Compression vs. low compression Patient suitability for compression Rationale bandaging Three RCTs compared elastic high compression three- layer bandaging (two using Tensopress and one Rationale Setopress as a component) with low compression Patients with arterial disease are not suitable for high (using Elastocrepe) (Callam et al 1992. More patients worsen ischaemia. * if wound large and heavily exuding. Travers et al 1992). Although the (Duby et al 1993).8 in another RCT in which patients with either four- (the presence of the latter readings do not necessarily layer or short stretch bandaging healed faster than diagnose an ulcer as arterial).8.2. single-layer ulcer care expert. Furthermore. Randomised controlled trials (RCTs) have shown Patients with this condition usually require some that compression provided either by Unna’s boot form of reduced compression. or short stretch bandages (Charles 1991) improved healing 2. correct interpretation of that assessment. This recommendation is based mainly on the logic Nelson et al 1995b. Strength of evidence (I) This recommendation is based on one large and two small trials The management of patients with venous leg ulcers Recommendations 13 . vascular Strength of evidence (I) surgeons may use a lower cut-off point. (Moffat et al 1995). Moffatt et al 1992). People with venous ulcers usually were healed at 12-15 weeks with high compression. et al 1984). compression therapy as it can decrease perfusion and unpublished. no compression This guideline does not address compression Rationale bandaging in patients with mixed aetiology.7 (Moffatt et al 1995) and in one study reduced achieves better healing rates than low compression compression was used in patients with an ABPI of 0. two-layer (Eriksson expertise in application and close monitoring.1 Graduated multi-layer high compression rates compared to treatments using no compression.6/0. systems (including short-stretch regimens). Northeast et al 1990). adhesive compression bandage (Kralj et al unpublished. Gould et al. cut-off point below which compression is not recommended is often quoted as 0. Arterial The advantage of higher compression was confirmed involvement is suggested by an APBI of less than 0.5 (four RCTs). and principles of pathophysiology. Sikes 1985). compression therapy is more cost- with adequate padding. mixed venous/arterial those receiving a paste bandage with outer support ulcers may have an ABPI of 0. the importance of adequate assessment. the use of compression on patients with a reduced APBI requires assessment and supervision by an experienced and trained leg Multi-layer vs. which requires (Rubin et al 1990. have an ABPI equal to or greater than 0. Rationale prescription of appropriate compression systems and The advantage of multilayer high compression their meticulous application cannot be over-stressed systems over single layer systems is shown by one (Cullum 1994).

one cross-sectional study). the 2 available obtain better and more consistent pressure results trials do not provide information on the relative (Logan et al 1992. bandaging has been compared with short stretch Incorrectly applied compression bandages may be and with Unna’s boots in 4 RCTs (Colgan et al harmful or useless and may predispose the patient unpublished. 2. there is little reliable evidence which provide a compression therapy service requires directly compares 4-layer with other types of formal evaluation. The consensus group was confidence that there are not clinically important able to give several examples where staff are not differences in effectiveness. However. When clinics Inexperienced nurses or those without additional have specifically promoted the delivery of 4-layer training in compression bandaging apply bandages high compression treatment. they appear not to have been directly it is important that it is used correctly so that compared with 4-layer bandaging in RCTs. more research is needed to see what training strategies improve compression bandage techniques and if the effects of training are maintained over time. compression were easier to apply correctly than single-layer bandaging and protocols for treatment and referral bandages (Stockport et al 1997). compression must be applied studies were small in size. Stockport et al care given by community nurses (Morrell et al 1997). 4-layer with 3-layer bandaging is being carried out at St. In the presence of 1996. Taylor et al 1998) and a trial ascertain from existing studies if these results are comparing 4-layer with short stretch is under way maintained over time. 4-layer sufficient (but not excessive) pressure is applied. London. there cannot be with extreme caution. Taylor et al 1998). compression bandaging in RCTs. The consensus group view was that it is essential that only properly trained staff apply compression bandages. effective. A trial comparing trained in applying compression bandaging. Nelson et al 1995a. 14 The management of patients with venous leg ulcers Recommendations . Strength of evidence (II) There is fairly reliable research evidence supporting the recommendation (a one-sample follow-up study. However. their healing rates at inappropriate and widely varying pressures have improved compared with results for the usual (Logan et al 1992. Duby et al 1993.0 The management of venous leg ulcers Four-layer vs. other types of 2. Scriven et al 1998). However. One study impact of. Knight & McCulloch to cellulitis or skin breakdown. Thomas’s Hospital. More experienced or well trained bandagers 1998. 2-layer and other Rationale compression bandages have been shown to be Whichever high compression approach is employed. Whether nurses who coordinated by the CEBN. It is difficult to (Morrell et al 1998. or interactions between the various found that multilayer compression bandage systems elements of setting. nurse training.2 The compression system should be applied compression bandaging by a trained practitioner Rationale Even though 3-layer. No differences were diabetes or any other condition that compromises found in healing rates. Nelson et al 1995a). because these arterial circulation. consistently find it difficult to apply a compression bandage should be given additional training or Strength of evidence II whether it is more appropriate to promote the use of a core team of nurses skilled in bandaging to Currently.

to 1995). Stevens et al 1997. Hofman et al 1997. Fifty per cent of patients with purely venous aetiology reporting severe pain were taking either mild analgesia or none at all (Hofman et al 1997). there is fairly strong evidence in support of the recommendation from one controlled trial. There is also some evidence that pain relief which may consist of compression therapy.0 The management of venous leg ulcers Strength of evidence (II) Pain assessment and relief Although the research is quite heterogeneous. The management of patients with venous leg ulcers Recommendations 15 .034). Yet. However.4 Use of compression stockings reduces one survey found that 55% of district nurses did venous ulcer recurrence rates not assess patients’ pain (Roe et al 1993).13). No research could be identified that meet the needs of the patient examined the use of a pain assessment method specifically designed for patients with venous leg ulcers or compared different methods of relief. studies). Dunn 1997.refer ulcers (NHSCRD1997) found no RCT which to recommendation 1. Drug tariff recommendations for Analgesics containing opioids may be necessary in compression hosiery some patients. A significant proportion of patients with venous ulcers report moderate to severe pain (Cullum & Prevention of recurrence of ulceration Roe 1995. compared recurrence rates achieved with and Leg elevation is important since it can aid venous without compression stockings in people with return and reduce pain and swelling in some healed ulcers. the 2. leg elevation may make the pain – five year recurrence rates were lower in patients worse in others (Hofman et al 1997). One RCT however. were better tolerated by patients (Harper et al 1995). class two calf pump function. There is very little conclusive research on other pain Rationale relief strategies such as exercise and leg elevation. Increased pain on mobility may be associated with poorer healing rates (Johnson 1995) and may also be a sign of some underlying pathology such as arterial Rationale disease or infection (indicating that the patient The EHCB Compression therapy for venous leg requires referral for specialized assessment .2. 2.3 Health professionals should regularly results consistently report that patients with venous monitor whether patients experience pain leg ulcers can experience considerable pain (one associated with venous leg ulcers and prospective. Exercise maintains the venous compression stockings (32%) (p=0. Class I 14-17mmHg at the ankle for light support Class II 18-24mmHg at the ankle for medium support Class III 25-33mmHg at the ankle for strong support Strength of evidence (II) Although no RCTs were found. Compression using strong support from class three compression counteracts the harmful effects of venous stockings (21%) than in those randomized to hypertension and compression may relieve pain receive medium support from class two (Franks et al 1995). Walshe 1995). one matched and two cross-sectional formulate an individual management plan. Hamer et al 1994. occurs with compression and healing (Franks et al exercise. stockings however. showed that three patients. leg elevation and analgesia.

• encouragement of mobility and exercise • elevation of the affected limb when immobile 16 The management of patients with venous leg ulcers Recommendations . • regular follow-up to monitor skin condition for recurrence • regular follow-up to monitor ABPI Strength of evidence (III) There is little evidence evaluating the effectiveness Patient education of each of these strategies . The Clinical recommended approach will depend on the • venous investigation and surgery particular patient and likely compliance with • lifetime compression therapy (see 2. 2. A variety of strategies have been proposed.much of the published • compliance with compression hosiery research is based on what is judged to be current best • skin care practice and clinical common-sense.4) suggested strategies. There is some • discourage self-treatment with over-the- evidence for the importance of early self-referral counter preparations from a trial (Moffatt & Dorman 1995). skin breakdown the shorter the time to rehealing.5 Other strategies for the prevention of Rationale recurrence may also include the following. which showed • avoidance of accidents or trauma to legs that the more quickly someone re-attends to receive • early self-referral at signs of possible 4-layer compression bandaging after recurrence. which range from medical investigation to health education. largely depending on the needs of the patient based on expert opinion.0 The management of venous leg ulcers 2.

e. other sites of the patient or vitro (Lineaweaver et al 1985). with warmed tap water or saline is autolytic.2 Removal of necrotic and devitalized tissue • irrigation of the ulcer.1 Cleansing of the ulcer should be kept simple: 3. chemical or enzymatic usually sufficient debridement • dressing technique should be clean and aimed at preventing cross-infection: strict asepsis is unnecessary Rationale A systematic review (Bradley et al. involving saline or antiseptic-soaked gauze. however there have There are no trials comparing aseptic technique been no randomized controlled trials of their use and with clean technique in chronic wounds. The purpose The chemical agents 1% providone iodine. Chemical debridement is harmful to cells– in vitro studies for example. and leg ulcers. with specific training in this skill as it is essential that underlying structures are not damaged. however.25% of the dressing technique is not to remove bacteria acetic acid. A trial of clean versus aseptic trials of these solutions in leg ulcers.3. There are no trials comparing aseptic compared to a variety of standard treatments. patients’ perceptions of this therapy have not been researched. Strength of the evidence (III) Moist wound environment aids debridement– no trial evidence could be found. contact sensitivity Cleansing Debridement 3. can be facilitated through the maintenance of a moist wound environment. usually technique with clean technique in chronic wounds.0 Cleansing.g. however. It is acknowledged. Cleansing traumatic wounds with tap manner unlikely to delay healing. Autolytic debridement. dressings. The use of maggots as biological debriding agents is Strength of evidence (III) enjoying a resurgence in the UK.5% but rather to avoid cross-infection with sources of hypochlorite have been shown to damage cells in contamination. where necessary can be achieved through mechanical. Nevertheless. the technique in the cleansing of tracheotomy wounds consensus view is that they should not be used. it is possible to maintain a moist wound environment under simple non-adherent dressings as moisture is retained beneath the bandage. that clinicians may any benefit and some evidence from studies of wish to remove sloughy or necrotic tissue from the animal models and cell culture that it might be ulcer bed and this should be accomplished in a harmful. including current evidence does not support their use. facilitate healing compared to these alternatives. failed to demonstrate any difference in infection The second generation chemical debriding agents rates between the two methods (Sachine-Kardase et dextranomer and cadexomer iodine have been al 1992). Sharp debridement water was associated with a lower rate of clinical is a relatively swift and inexpensive method of infection when compared to sterile isotonic saline debridement but must be undertaken by someone (Angeras et al 1992). and may including leg ulcers. The management of patients with venous leg ulcers Recommendations 17 . Lineaweaver et al (1985). In patients wearing compression bandages. 0. Wounds and skin are colonized with bacteria and these do not appear to impede healing. there are no other patients. debridement. the breakdown and removal of dead tissues by the body’s own cells and enzymes. in press) concluded that there have been no trials which measure the Rationale impact of debridement on the time wounds take to There is no evidence that use of antiseptics confers heal. 3% hydrogen peroxide and 0.

4 Health professionals should be aware that The evidence for the recommendation is based on patients can become sensitized to elements observation and clinical experience. Malten et al 1973. Paramsothy et al 1988). Following Patients can develop allergies after using a product patch testing.6 Patients with suspected sensitivity reactions should be referred to a Rationale dermatologist for patch testing. Treatment will vary and may consist of elevation of the affected limb and application of steroid ointment. It is important that these are identified so that they may be avoided in future. low 3. Strength of the evidence (III) 3. 1988. Rationale Strength of evidence (II) A large proportion of patients with venous leg ulcers One cohort study (Cameron.5 Products which commonly cause skin cost and acceptable to the patient sensitivity such as those containing lanolin and topical antibiotics should not be used on any patient Rationale A recent systematic review (Bradley et al in press) Rationale has concluded that there is no evidence that any particular dressing or dressing type is more Patients with venous leg ulcers have high rates of effective in healing venous leg ulcers. Kulozik et al not recommended. the safest course dressings and topical agents in patients with venous is to avoid these products wherever possible.3 Dressings must be simple. wet to dry gauze is Goossens et al 1979b. 18 The management of patients with venous leg ulcers Recommendations . low adherent. Dooms- the ulcer bed. of their treatment at any time 3. Cameron 1990. Fraki et al 1979. Cameron et al 1991. 1998) are allergic to a number of commonly used products (Dooms-Goossens et al 1979a. dressings. dressings should be low cost examined in a number of studies (Blondeel et al and low or non-adherent to avoid any damage to 1978. The most sensitivity to these products. McLelland & Shuster 1990). Preparations commonly important aspect of treatment for uncomplicated used as part of leg ulcer treatment reported to cause venous ulcers is the application of high contact sensitivity in certain individuals are listed below. Given that skin condition Strength of the evidence (I) can be improved using products without lanolin. 3. that there is no evidence that topical antibiotics aid A recently completed systematic review (Bradley et healing and that patients may develop a sensitivity al in press) identified 42 randomised trials of after using the product for a while. identified allergens must be over time. debridement. Strength of evidence (III) The evidence supporting this recommendation is based on observation and clinical experience. Frequency of contact sensitivity and the compression using a stocking or bandage. In the commonest sensitizers in leg ulcer patients have been absence of evidence. For this reason. ulcers and concluded there was insufficient evidence to promote the use of any particular dressing. Cameron (1998) found that more than avoided and medical advice on treatment 20% of patients previously patch tested had should be sought developed at least one new allergy at retesting 2 and 8 years later. contact sensitivity Dressings Contact sensitivity 3.0 Cleansing. Malten & Kuiper 1985.

latex gloves worn by carer chlorocresol biocide corticosteroid creams and some moisturizers quinoline mix biocide antiseptic and antifungal creams and ointments chlorhexidene biocide antiseptics. tulle dressing tixocortal pivalate steriod steroid preparations. debridement. bacitracin antibiotic medicaments.hydrocortisone fragrance mix/balsam of Peru perfume bath oils. elastic stockings. framycetin. emollients. contact sensitivity Table 1: Common allergens and their importance in the care of venous ulcers Name of allergen Type Potential sources wool alcohols. tulle dressing. aqueous cetylstearyl alcohol. antibiotic creams and ointments parabens (hydroxybenzoates) preservative medicaments. vehicle most creams. cetostearyl alcohol cream. lanolin bath additives.0 Cleansing. amerchol L 101. emulsifying ointment and some paste bandages colophony/ester of rosin adhesive adhesive backed bandages and dressings mercapto/carba/thiuram mix rubber elastic bandages and supports. over the counter preparations such as moisturizers and baby products The management of patients with venous leg ulcers Recommendations 19 . eg.3. stearyl alcohol. barriers and some e baby products neomycin. creams. creams and paste bandages cetyl alcohol. including corticosteriod creams. dressings.

research-based ulcers (NHSCRD 1997). Hence. standards impact of different training programmes on patient require continual monitoring.and post-test recurrence rates. information and knowledge about aetiology. there is some evidence from pre. rates of healing and • criteria for referral for specialised adverse outcomes due to incorrectly treated arterial assessment disease or excessive compression) ensures that appropriate performance indicators are monitored. Research using non. randomised comparison groups or pre. time to complete healing. There is a need for well- designed. consensus based.) would need to be collected to assess (Dealey.and post- test analysis of non-randomized comparison groups that knowledge of leg ulcer care is improved by training (two studies). outcomes and the long-term impact on nursing knowledge. there is little research on the than staff expected. Much of the published audit-related research has Strength of evidence (III) used weak designs that have not sufficiently examined the impact of monitoring systems on Most existing research in this area is presented patient outcomes.1 Health care professionals with recognized 5. the ABPI proportion of patients treated by appropriately • normal and abnormal wound healing trained staff). a specific training approach is Strength of evidence (III) not recommended. The recommendation is within the context of a poorly reported audit study. of patients whose arterial status has been management. application determined by ABPI measurement. 4. the prevalence of active ulceration. patient designs has shown that community nurses’ knowledge health status. a large number of variables (eg. Luker & Kenrick 1995). prospective studies which evaluate the impact of well-described educational interventions on nursing practice and patient outcomes. but that ulcer free leg). adjusted for case-mix..0 Education/training in 5.1 Systems should be put in place to monitor training in leg ulcer care should cascade their standards of leg ulcer care as measured by knowledge and skills to local health care structure. in press. consequently. some evidence to suggest that information packs and Another comment was that many audits have videos are a valuable adjunct to study days (Nelson & revealed that patient outcomes were much poorer Jones 1997). before-after designs and often fail to describe in adequate detail the education programme or baseline skill mix of the participants. process and outcome teams. Rationale from the EHCB Compression therapy for venous leg To reduce variation in practice.0 Quality assurance leg ulcer care 4. However. Concern was expressed by a consensus group assessment and management is required (Morrell et al member that for audit to be of benefit in leg ulcer 1998. the proportion • compression therapy . • preventing recurrence proportion of patients healed. Simon et al 1998). There is also whether meaningful change has taken place. and the • dressing selection proportion with uncomplicated venous ulcers • skin care and management receiving high compression therapy) and outcome • health education (for example. This should include providing education on the following • pathophysiology of leg ulceration • leg ulcer assessment Rationale • use of Doppler ultrasound to measure Measurement by structure (for example. patient-centred outcomes (such as an of leg ulcer management is often inadequate. utilizing one-sample. process (for example.theory. In the absence of such research. this recommendation is based on consensus opinion. care. However. 20 The management of patients with venous leg ulcers Recommendations . healing rates. ulcer size etc. knowledge can be improved by provision of training setting etc.

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