Guest posting from Dr Nicole Organ, Vascular Surgeon, HNE LHD

Golden rules

1. Maintain lower limb skin integrity – trauma avoidance, protective routine skin care
2. Treat acute lower limb wounds/skin tears aggressively to prevent chronicity – early use of wound compression
3. Address modifiable risk factors – superficial venous disease, obesity, sedentary lifestyle, arterial disease
4. Use simple approach to wound dressing that removes excess fluid and avoids maceration but avoid combines or zetuvit under compression bandages
5. Use topical agents that have good evidence supporting their use
6. Always take sequential photos to track healing
7. Refer wounds to specialist if not healing or increasing in size despite adequate compression
8. Only take wound swabs for culture if there is good evidence of wound cellulitis
9. Avoid wound treatments that don’t make a difference or that may be harmful (below)

Wound treatments with some evidence in the treatment of chronic venous ulceration

• Multilayer compression bandages and sequential compression pumps (Compression bandages and stockings to help the healing of venous leg ulcers | Cochrane)
• Cadexomer iodine (Antibiotics and antiseptics to help healing venous leg ulcers | Cochrane)

Wound treatments without strong evidence in the treatment of chronic venous ulceration:

• Systemic antibiotics
• Wound debridement
• Topical antiseptics including honey, silver, hypochlorite
• Hydrocolloid dressings
• Alginate dressings
• TED stockings
• Negative pressure wound dressings

Assessment approach

• assess risk factors (+/- modifiable)
• assess wound – diagnosis (? arterial, venous or microcirculatory disease, infection, vasculitis) , underlying conditions, (neuropathy, clotting, metabolic, haem disorder) document, photograph and care for whole patient
• beware malleolar wounds – pictures below (difficult to heal, arterial and venous components require management, possible underlying osteomyelitis)

References

• Australian and New Zealand Clinical practice guidelines for prevention and management of venous leg ulcers, 2011 Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg U (woundsaustralia.com.au).
• Cochrane database of Systematic reviews (Venous leg ulcers: evidence review – Evidently Cochrane)