Best practices for the prevention and treatment of venous leg ulcers.

Chronic venous insufficiency is the most common cause of leg ulcers. Its incidence increases as the population ages. Managing venous leg ulcers involves treating the cause, optimizing local wound care, and addressing patient-centered concerns. The cornerstone of the diagnosis of chronic venous insufficiency includes demonstrating venous disease. The clinician must rule out significant coexisting arterial disease by performing a thorough clinical assessment and obtaining an ankle brachial pressure index. The most important aspect of treatment is resolving edema through high compression therapy for those individuals with an ankle brachial pressure index greater than or equal to 0.8. Other components of successful chronic venous insufficiency management include increasing mobility and medical management. Selected patients may respond to surgery, biologicals, adjunctive therapies, and lifestyle enhancements. Twelve recommendations are made incorporating current best clinical practices and expert opinion with available research. The approach to venous disease is best accomplished through a multidisciplinary team that revolves around the active participation of patients and their families. The authors' intent is to provide a practical, easy-to-follow guide to allow healthcare professionals to provide best clinical practices.

Assessment of venous leg ulcers: an in-depth discussion of a literature-guided approach.

Venous leg ulcers represent a significant public health problem that will increase as the population ages. The elderly, the most likely to be afflicted by this condition, present the clinician with special challenges. The diagnosis of venous leg ulcers involves taking a careful history, paying attention to the existence of factors that predispose individuals to the development of chronic venous insufficiency. Clinical features of venous insufficiency are important because their recognition allows clinicians to distinguish venous from other chronic ulcers. An essential part of the assessment of all patients with chronic wounds is an evaluation of intercurrent diseases, common in the elderly, which may impact on the wound healing process. Thus, in addition to managing venous insufficiency and the wound bed, all other factors, systemic and local, that may impede healing need to be investigated and corrected if necessary. Social and psychological issues common to all chronic illnesses need to be addressed as well. This holistic approach should be standard practice and is applicable to the assessment and management of all chronic leg ulcers. This often requires coordinating a multidisciplinary team of wound healing caregivers. More work needs to be done to clarify a few issues because areas of controversy persist. Although a great deal is known about the effects of vitamin deficiency on acute wounds, less is known about chronic ulcers. Similarly, the role of vitamin supplementation in managing chronic ulcers needs further study. Guidelines are needed to determine indications for wound culturing. In addition, more study is required to establish the most effective means of obtaining quantitative cultures. However, the relationship between bacteria and chronic wound healing goes beyond simple quantitation and other factors such as bacterial virulence and host resistance. These controversial issues will be reviewed. Treatment and prevention of venous leg ulcers will be discussed in a subsequent article.

Management and prevention of venous leg ulcers: a literature-guided approach.

Managing venous leg ulcers involves management techniques that are indicated both in the treatment of all chronic leg ulcers and those that are specific to venous leg ulcers. The first step in managing venous leg ulcers is performing a holistic assessment of the patient. Once this is complete, any systemic or local factors that may affect wound healing should be addressed. This approach to managing the whole patient is critically important because if significant general wound healing factors are not treated, other specific attempts at healing the venous ulcer will be fruitless. This paper reviews nutritional supplementation, wound bed preparation, antimicrobial therapy, venous insufficiency, compression therapy, different bandage systems, therapeutic adjuncts to compression therapy, and recent advances in vascular surgery. Recurrence prevention also is discussed.

The role of Apligraf in the treatment of venous leg ulcers.

A cultured, allogeneic, bi-layered human skin equivalent has recently become available to help clinicians manage difficult-to-heal venous ulcers. This skin equivalent has an epidermis and dermis similar to human skin. Its living keratinocytes and fibroblasts are from cultured cell banks derived from human neonatal foreskin. Because the skin equivalent is made up of viable human cells, it cannot be terminally sterilized. Safety concerns, which have been addressed, include the risk of possible transmission of infection, immunogenicity, immunological graft rejection, and tumor formation. However, the maternal blood of the neonatal donor and the master cell banks are screened for infectious agents. Additionally, the human skin equivalent is produced under strict aseptic control, with sterility continuously monitored by the Good Manufacturing Processes. This paper reviews the characteristics of this human skin equivalent and provides practice guidelines.

Growth factors in wound healing: the next great innovation?

Wound healing is a complex process that, in the vast majority of cases, normally leads to complete healing. It can be likened to the construction of a building, having many of the same requirements. As long as these requirements are satisfied, the healing of the acute wound proceeds uneventfully. Unfortunately, significant impediments to healing occasionally exist and the acute wound stops healing, becoming chronic. If these impediments can be controlled, most of these chronic wounds will eventually heal, albeit slowly. For example, the venous leg ulcer will heal once one applies proper compression therapy that provides the necessary support counteracting the underlying venous hypertension and provides appropriate wound care. Similarly, diabetic neuropathic foot ulcers will not heal until the disordered glucose metabolism is controlled and causative pressure on the foot is offloaded. Thus, successful healing of chronic wounds involves the treatment of underlying causes. Sometimes, however, proper management of these underlying diseases does not result in healing. Conventional therapy, unfortunately, does not have an answer for this dilemma. Growth factors provide a means by which cells are able to communicate with each other. They have profound effects on cell proliferation, migration, and extracellular matrix synthesis and release. Considering applying topically active growth factors directly to the wound surface in order to stimulate some aspect of the healing process has always been attractive. To date, Platelet-Derived Growth Factor (PDGF) has been the most researched of all the growth factors. Originally studied in the management of pressure ulcers, PDGF was eventually approved in North America for the treatment of diabetic lower extremity ulcers. The clinical data surrounding these indications will be reviewed. The future in growth factor research may require a greater understanding of how these substances interact with each other. Wound dressings of the future may include several growth factors, each with a specific function. In this way, the application of topically active growth factors to chronic ulcers just might be the next great innovation in wound healing.