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easy
Challenges of venous
leg ulcer management
© Wounds International | April 2022 www.woundsinternational.com

Introduction A
Venous leg ulcers can cause severe morbidity to patients
Deep
in terms of complications with wound healing and the Superficial vein
vein
wider impact of a highly exuding wound on all aspects
of daily life. Although exudate contains components
that support healing, excessive exudate impairs healing
and increases the risk of infection and periwound
maceration (WUWHS, 2019). Optimal management of the
Perforator
challenges is therefore a priority to achieve faster healing vein
times and limit patient morbidity. This Made Easy offers
examples of solutions to achieve optimal outcomes for
patients, including periwound skin protection, exudate
management, infection identification and management Healthy working valves
and compression therapy. In healthy individuals, venous blood flows from the
superficial veins, through perforator veins to the deep
venous system from where it returns to the heart assisted
Definition and aetiology by the action of the calf muscle pump.
A venous leg ulcer (VLU) is an open skin lesion that usually
occurs on the medial aspect of the lower leg between the
ankle and the knee as a result of chronic venous insufficiency
(CVI) or ambulatory venous hypertension, and shows
little progress towards healing within 4-6 weeks of initial
occurrence (Harding et al, 2015). B
Deep
CVI is the result of damage to the valves in the veins of the
vein
legs, associated with varicose veins or venous thrombosis. The
damaged valves interrupt the normal functioning of the veins;
as a result, impaired venous drainage from the legs and chronic
venous hypertension cause the leg capillaries to leak fluid, blood Damaged
cells and proteins into local tissue. This triggers an inflammatory valve
response that further exacerbates venous hypertension,
damages leg tissues and restricts skin oxygenation (Harding et al,
2015; Figure 1).

Challenges of VLU exudate

management
VLUs can be difficult to heal due to poor management
of the underlying condition, which leads to high rates of
reoccurrence – 55% of healed VLUs reoccur within the first
12 months of closure (Finlayson et al, 2018).
The key challenges in VLU management can be summarised into
four main areas:
1. Exudate management
2. Periwound skin maceration
3. Infection risk and presence of infection
4. Patient compliance.
Compromised venous system
When valves are damaged or compromised (made
incompetent) this system fails, venous reflux (backward
flow) occurs and pressure in the veins fails to fall
adequately on exercise causing venous hypertension.
Over time this causes progressive skin damage.
Figure 1: A) Venous return in individuals with working valves;
B) Compromised venous return in individuals with incompetent venous
valves (adapted from Vowden and Vowden, 2012; Vowden et al, 2020)

1
 made
easy
Challenges of venous
leg ulcer management
1. Exudate management
Exudate is both a problem and a benefit in wound
management. Exudate contains components that are necessary
for would healing, such as electrolytes, nutrients, proteins,
inflammatory mediators, matrix metalloproteinases (MMPs),
growth factors and other cells and molecules (White and
Cutting, 2006).
Exudate originates in serous fluid leaked by the capillaries into
surrounding tissues. Normally, about 90% of the leaked fluid is
reabsorbed by the capillaries and 10% returns to the circulation
via the lymphatic system. However, when a wound is present,
additional fluid is produced by the capillaries and enters the
wound bed where it forms exudate to help heal the wound
(Wounds UK, 2013).
An excess of exudate is involved in a number of interrelated
problems. Excess exudate increases the risk of bacterial
colonisation, infection and biofilm of the wound; causes
protein loss, and fluid and electrolyte imbalance; precipitates
maceration of the periwound skin; and causes malodour,
discomfort and pain, all of which increase the patient’s pain and
distress (Wounds UK, 2013; WUWHS, 2019).
Poorly managed exudate contributes to periwound maceration,
which is associated with infection, as well as with oedema
and lymphoedema (Sandy-Hodgetts et al, 2020). Poorly fitting
bandages can also lead to exudate leakage, which is a problem
for patients and contributes to periwound skin damage.
2. Periwound maceration
Wound healing requires the epidermal margins of the wound
to migrate across the wound bed, followed by maturation of
the skin to protect the wound site from future damage. If the
wound bed is prepared effectively, the best conditions will be
created for successful re-epithelialisation (i.e. debridement of
non-viable tissue, management of excess exudate).
The periwound epidermis of VLU is typically thickened and
highly keratinised (Schultz et al, 2005). It should therefore be
carefully removed to promote migration of the wound edges to
close the wound (Dowsett and Newton, 2005).
3. Infection risk and presence of infection
Bioburden is one of the most serious barriers to wound healing,
and can be life threatening. Infection and associated inflammation
not only cause the individual pain and discomfort, but also delay
healing, and increases the cost and number of interventions
needed to treat the wound, exacerbating the impairment of the
patient’s quality of life. Biofilm, present in greater than 70% of
chronic wounds, causes persistent inflammation and poor wound
healing (WUWHS, 2016; Malone et al, 2017).
It is believed that a contributing factor of impaired healing in
chronic leg ulcers is an increase in inflammatory mediators rather
than a deficiency of growth factors (Trengove et al, 2000).
4. Patient compliance and quality of life impact
Leg ulceration has a severe impact on a patient’s work and social
life, and activities of daily living, including personal hygiene.
Ulceration can have a profound emotional and psychological
impact including shame, embarrassment, loneliness, anxiety and
depression, as a result of risk of malodour, exudate leakage and
discomfort (Green et al, 2014; González de la Torre et al, 2017;
Platsidaki et al, 2017). One systematic review found that wound
pain, malodour and exudate, and the pain involved in treatment
had significant negative impacts on quality of life, including sleep,
mobility and mood (Phillips et al, 2018).
These challenges in wound healing delay VLU healing, alongside
other factors such as inadequate or incomplete assessment of the
wound and the person’s needs, poor dressing selection and use,
and ineffective use of compression therapy (Guest et al, 2018). Best,
evidence-based practice not only helps to reduce resource use and
staff time, but also greatly eases the impact on patients’ quality of life.
Solutions
Accurate diagnosis and assessment
It is important to distinguish VLU from other kinds of lower
limb ulceration, such as arterial leg ulcers, mixed-aetiology
ulcers and diabetes-related ulcers and identify the underlying
cause of the ulcer – in this case, CVI (Harding et al, 2015).
Wound assessment should pay attention to location, duration
and size of the wound, exudate levels, the condition of the
wound bed and surrounding skin and limb (Harding et al,
2015).
Management
Best practice in VLU healing and local wound management
requires the following:
■ Skin protection
■ Preparation of the wound bed to manage biofilm/bioburden
■ Optimisation of the wound environment to manage exudate
and support granulation, protect skin integrity, restore
damaged skin and promote re-epithelialisation, and control
exudate and infection.
■ Therapeutic compression.
Alongside local wound management, consider the
individual's need for vascular intervention to reduce risk of
ulcer recurrence. Figure 2 includes examples of solutions
from the 3M range that can be used as part of a holistic VLU
management regimen.
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Figure 2: Solutions for VLU management using examples from the 3M™ range

3
Skin protection
The wound and surrounding tissues need to be in the best
condition to promote wound healing. They need to be carefully
assessed and managed to limit a prolonged inflammatory
response, reduce the risk of infection and promote re-
epithelialisation.
Skin damage, such as maceration, erythema and weeping,
are often associated with VLUs. Research supports routine
protection of the periwound skin and at-risk, compromised skin
from excess exudate and mechanical trauma as essential parts
of wound management and wound bed preparation (Bryant
et al, 2016). Use of non-sting barrier film (e.g. 3M™ Cavilon™
No Sting Barrier Film) has been shown to lead to significantly
greater wound size reduction compared to use of a barrier
cream or not using a skin protectant at all (Guest et al, 2012).
The retrospective data analysis also suggests that using a non-
sting barrier film may facilitate the healing of larger wounds
without increasing costs.
Preparation of the wound bed to manage infection,
biofilm and bioburden
The first step in preparing the wound bed is identifying
the related signs and symptoms of infection, biofilm and
bioburden. The clinical signs of local wound infection are new,
increased or altered pain and delayed healing. Additional
signs are periwound oedema, bleeding or friable granulation
tissue, malodour or change in odour, discoloration of
the wound bed, increased or altered purulent exudate,
induration, pocketing and bridging (WUWHS, 2009).
The management of bioburden should be focused on two
critical areas:
1. The optimisation of the patient’s ability to fight infection.
This includes optimising hydration and diet and addressing
systemic promoters of infection, such as sub-optimal
management in diabetes.
2. The reduction of bacterial load in the wound to prevent
further wound contamination or cross-contamination
and promote wound drainage. The wound bed should be
debrided to remove non-viable tissue (e.g. necrotic tissue and
slough) to leave the wound bed with functional extracellular
matrix proteins and optimal characteristics for healing
(Dowsett and Newton, 2005).
Optimising wound environment
The TIME framework is recommended for assessment and
management of VLU (Harding et al, 2015). The TIME framework
offers an evidence-based approach, which pays close attention
to four aspects of wound bed preparation: tissue management,
the control of infection and inflammation, management of
moisture and exudate, and re-epithelialisation at the edge of
the wound (Schultz et al, 2004).
Dressing selection for biofilm or bioburden
Biofilm or bioburden may be managed with a non-adherent
antimicrobial dressing containing silver (e.g. 3M™ Silvercel™ Non-
Adherent Hydro-Alginate Antimicrobial Dressing or 3M™ Promogran
Prisma™ Matrix [Vin et al, 2002; Wollina et al, 2005; Cullen et al, 2017;
Smeets et al, 2008]). Applying a super-absorbent dressing (e.g. 3M™
Kerramax Care™ Super-Absorbent Dressing) may help remove excess
exudate from the wound bed while also isolating and locking away
harmful bacteria and MMPs away from the wound bed (Gibson et al,
2009).
Dressing selection for exudate management
Selecting products that help maintain an optimal environment
through exudate management, provide protection from outside
contaminates, and enable easy application and removal are
important to wound healing.
Appropriate dressing selection is a critical factor in the management
of exudate (Table 1). However, the most effective tool for reducing
excess exudate is sustained and appropriate compression therapy
(Harding et al, 2015). In complex cases of VLUs that persist unhealed
despite optimal wound bed preparation and compression therapy,
advanced tools such as negative pressure wound therapy should be
considered (Harding et al, 2015).
Therapeutic compression
Compression therapy is the gold standard for VLU
management and has been shown to increase the rate of
healing compared to no compression therapy. Research
indicates that a bandage or multi-layer compression system
that is capable of creating an inelastic sleeve provides
stiffness that effectively supports venous pump mechanisms
(e.g. 3M™ Coban™ 2 Two-Layer Compression System; Partsch,
2005; Mosti and Partsch, 2010).
Compression works by enclosing the leg with a garment – a
bandage, hosiery or wrap system – that produces evenly
distributed pressure within. As external pressure rises, fluid is
forced out of the limb. Firm but flexible compression with high
stiffness produces a massaging effect that promotes venous
return better than elastic systems (Partsch, 2003).
Additional haemodynamics effects of compression therapy
include (Partsch and Mortimer, 2015; Partsch and Moffatt, 2015;
Moffatt et al, 2012; Mosti, 2018):
■ Reduced venous ambulatory hypertension and venous pooling
■ Improved venous and lymphatic return
■ Reduced chronic oedema and inflammation
■ Reduced leg pain.
4
 made
easy
Challenges of venous
leg ulcer management

Table 1. Guide to product and dressing selection for venous leg ulcers
Step 1 Skin protection Barrier film 3MTM CavilonTM No Sting Barrier Film
Step 2 Maceration treatment Durable, long-lasting 3MTM CavilonTM Advanced Skin Protectant
barrier film
Step 3 Infection control Antimicrobial dressing 3MTM KerracontactTM Ag Dressing, 3M™ Silvercel™
short-term Non-Adherent Hydro-Alginate Antimicrobial Dressing,
3M™ Promogran Prisma™ Wound Balancing Matrix
Step 4 Wound Exudate low Adherent dressing 3MTM TegadermTM Absorbent Clear Acrylic Dressing
dressing
Exudate moderate Conformable, absorbent 3MTM TegadermTM High Performance Foam Dressing
dressing
Exudate high Alginate, other gelling fibre, 3MTM TegadermTM Silicone Foam Border Dressing
or foam dressing
Exudate very high Super-absorbent 3MTM Kerramax CareTM Super-Absorbent Dressing
dressing
Step 5 Therapeutic compression Compression bandaging 3MTM CobanTM 2 Two-Layer Compression System (ABPI >0.8)
3MTM CobanTM Lite 2 Two-Layer Compression System
(ABPI ≥0.5–0.8)

A full assessment of the VLU and patient must be conducted
before prescribing compression, including assessment of arterial
circulation. An ankle­–brachial pressure index (ABPI) measurement
must be carried out by an appropriately qualified practitioner.
Patients with an ABPI <0.8, with diabetic foot ischaemia or
neuropathy, or cardiac failure must be referred for specialist
assessment before compression therapy can be considered
(Wounds International, 2013).
Supporting supported shared care
and beyond
A key component of encouraging the use of therapeutic
compression is to support patients and their carers to wear
their garments at home. Box 1 includes practical tips to
encourage patient compliance and supported shared care
with regard to wound care and compression therapy.
■ Engagement from staff with up-to-date knowledge to support
patient concordance with therapeutic compression.
Box 1. Practical tips when engaging the individual and/or their carers
in supported shared wound care
■ Explain the underlying disease
■ Discuss the clinical goals of the treatment
■ Provide a full explanation of the treatment
■ Describe compression as 'firm' not tight — this can really
make a difference!
■ Offer pain relief prior to any treatment
■ Avoid changing the dressing choice frequently — decide on
a treatment plan and follow it unless the wound condition
deteriorates

Conclusion ■ Remind the individual they need to wear footwear

Good exudate management relies on a careful assessment
of the signs that indicate high levels of exudate, such as the
presence of maceration and excoriation of the periwound
skin, and the presence of malodour. Management of the
challenges of VLU management requires the following:
■ Attention to assessment of the wound at dressing changes
■ The selection of the most appropriate and effective wound
care products to treat the condition of the wound and exudate,
to minimise the risk of maceration and to suit the individual’s
psychosocial preferences
■ Prompt response to changes in condition of the wound or
appearance of the signs of infection
■ Encourage good skin care with emollients
■ Once healing is achieved, ensure compression stockings are
worn as a preventative measure.
The results and outcomes of the case study should not be interpreted as guarantee or warranty
of similar results. Individual results may vary depending on the patient’s circumstances and
condition.
NOTE: Specific indications, contraindications, warnings, precautions, and safety information exist
for these products and therapies. Please consult product labelling prior to use. Please consult a
clinician and product instructions for use prior to application. Rx only. This material is intended for
healthcare professionals.

5
 Authors
Maria Hughes,
Independent Tissue Viability Consultant, Queen's Nurse, North Wales, Wales
Dr Bram Balduyck,
Thoracic and vascular surgeon, St. Jozef Hospital Bornem, Belgium

This Made Easy supplement was supported by an educational grant from 3M

© Wounds International 2022

Case Study: Use of 3M™ Kerramax Care™ Super-Absorbent Dressing and 3M™ Coban™ 2 Two-Layer Compression System in an individual with bilateral leg ulcers.
Patient data and photos courtesy of Maria Hughes.
A 65-year-old male presented with extensive bilateral leg ulceration present for
several months. Previous medical history included type 2 diabetes, fractured
right hip and long-term smoking. Previous wound treatment included foam
dressings, iodine and absorbent padding with daily dressing changes. However,
the wounds did not improve, and the foam dressings did not adequately manage
the high level of wound exudate.
At presentation, the lateral left leg and right medial malleolus wounds showed
extensive ulceration, dry skin, excoriation and maceration, oedema and evidence
of venous disease (Figures A-B). Cleansing and emollient therapy was prescribed
to improve the health of the surrounding skin. The patient’s ankle–brachial
pressure indexes (ABPIs) were 0.92. Due to the high levels of wound exudate,
KerraMax Care Dressings was initiated. As the patient showed limited healing
with extensive oedema, compression therapy using Coban 2 Compression
System was applied over the dressing (Figure C). Dressing changes occurred twice
weekly. Wound size reduction and periwound skin improvement were observed
after 2 weeks of KerraMax Care Dressing and Coban 2 Compression System use
(Figures D-G). After 4 weeks, dressing changes were reduced to once per week.
A wound infection at week 11 was resolved with topical antimicrobials and oral
antibiotics. The wounds healed after 15 weeks. The patient received ongoing care
to reduce the risk of recurrence, which included daily application of emollients by
relatives, wearing of bilateral hosiery socks, and the monitoring of his ABPI.
The patient reported improved satisfaction with the KerraMax Care Dressing
and Coban 2 Compression System use compared to the previous treatment,
especially with the reduction of dressing changes from daily to twice a week
to once a week. The patient also reported improved exudate management and
reduced lower extremity pain with this treatment combination.

A B
D F G

A. Lateral left leg wound at presentation. B. Right medial malleolus wound at presentation. C. Application of KerraMax Care Dressings and Coban 2 Compression
System. D. Lateral right wound after 2 weeks of KerraMax Care Dressings and Coban 2 Compression System use. E. Left malleolus wound after 2 weeks of
KerraMax Care Dressings and Coban 2 Compression System use. F. Lateral right wound after 9 weeks of KerraMax Care Dressings and Coban 2 Compression
System use. G. Lateral right wound after 13 weeks of KerraMax Care Dressings and Coban 2 Compression System use.

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