RISK FACTORS: Atopy, Superimposition of itch-scratch cycle, Trauma, Previous deep vein thrombosis, Previous pregnancy, Prolonged medical illness, Obesity, Secondary infection, Low-protein diet, Old age, Deposition of fibrin around capillaries
APPROPRIATE HEALTH CARE :
. Outpatient
. Inpatient for vein stripping, sclerotherapy or skin grafts
. Venous ulcer treatment includes autolytic, chemical, mechanical, surgical and biologic
. Autolytic - hydrogels, alginates, hydrocolloids, foams and films
. Biologic - topical application of granulocyte macrophage colony stimulating factor promotes healing of ulcers
. Chemical - enzyme debriding agents
. Mechanical - wet to dry dressings, hydrotherapy, irrigation
. Surgical modifying cause of venous hypertension, treat ulcer by graft
GENERAL MEASURES :
. Primary role of treatment is to reverse effects of venous hypertension
. Reduce edema:
. Leg elevation - heels higher than knees, knees higher than hips
. Compression therapy: elastic bandage wraps - Ace bandages or Unnas paste boot (zinc gelatin) if lesions are dry or compression stockings (Jobst or non-fitted type)
. Pneumatic compression devices
. Diuretic therapy (with caution to avoid dehydration)
. Treat infection:
. Debride the ulcer base of necrotic tissue
. Improvement of lipodermatosclerosis
SURGICAL MEASURES :
. Sclerotherapy and surgery may be required
ACTIVITY :
. Avoid standing still
. Stay active, exercise regularly
. Elevate foot of bed unless contraindicated
DIET : No special diet. Lose weight, if overweight.
PATIENT EDUCATION :
. Stress staying active to keep circulation and leg muscles in good condition. Walking is ideal.
. Keeping legs elevated while sitting or lying
. Dont wear girdles, garters, or pantyhose with tight elastic tops
. Dont scratch
. Elevate foot of bed with 2-4 inch blocks
DRUG(S) OF CHOICE
β’ If secondary infection, treat with oral antibiotics for staphylococcus or streptococcus organisms (eg,
dicloxacillin 250 mg qid; cephalexin 250 mg qid or levofloxacin 250 mg qd)
β’ Gram-negative colonization, treat with topical antimicrobial agents (e.g., benzoyl peroxide, acetic acid, silver
nitrate, or Hibiclens) or broad-spectrum topical antibiotics (eg neomycin or bacitracin-polymyxin b [Polysporin])
β’ 5% aluminum acetate (Burowβs solution) wet dressings and cooling pastes
β’ Topical triamcinolone 0.1% (Kenalog, Aristocort) cream/ointment tid or topical betamethasone
β’ Betamethasone valerate (Valisone) 0.1% cream/ointment/solution tid
β’ Topical antipruritic - pramoxine, camphor, menthol, doxepin
β’ Systemic steroids for severe cases
β’ Calcium dobesilate has been shown to be an effective adjuvant therapy
ALTERNATIVE DRUGS :
β’ Consider antibiotics on basis of culture results of exudate from ulcer craters
β’ Lubricants when dermatitis is quiescent
β’ Chronic stasis dermatitis can be treated with topical emollients (eg, white petroleum, lanolin, Eucerin)
β’ Antipruritics (e.g., diphenhydramine, cetirizine hydrochloride, desloratadine
PATIENT MONITORING : If Unnaβs boot is used - cut off and reapply boot once a week (restricts edema and prevents scratching)
PREVENTION/AVOIDANCE :
β’ Avoid recurrence of edema with compression stockings
β’ Topical lubricants twice daily to prevent fi ssuring and itching
POSSIBLE COMPLICATIONS:
β’ Secondary bacterial infection
β’ Deep vein thrombus
β’ Bleeding at dermatitis sites
β’ Squamous cell carcinoma in edges of long standing stasis ulcers
β’ Scarring, which in turn leads to further compromise to blood fl ow and increased likelihood of minor trauma
EXPECTED COURSE/PROGNOSIS:
β’ Chronic course with intermittent exacerbations and remissions
β’ The healing process for ulceration is often prolonged and may take months