Consistent application of compression: An under-considered variable in the prevention of venous leg ulcers.

Venous leg ulcers, the most common leg ulcer, occur in patients with chronic venous insufficiency due to venous hypertension. Evidence supports the conservative treatment with lower extremity compression, ideally between 30-40 mm Hg. Pressures in this range provide enough force to partially collapse lower extremity veins without restricting arterial flow in patients without peripheral arterial disease. There are many options for applying such compression, and those who apply these devices have varying levels of training and backgrounds. In this quality improvement project, a single observer utilised a reusable pressure monitor to compare pressures applied using different devices by individuals in wound clinics with diverse training from specialties of dermatology, podiatry, and general surgery. Average compression was higher in the dermatology wound clinic (n = 153) compared to the general surgery clinic (n = 53) (35.7 ± 13.3 and 27.2 ± 8.0 mm Hg, respectively, p < 0.0001), and wraps applied by clinic staff (n = 194) were nearly twice as likely as a self-applied wrap (n = 71) to have pressures greater than 40 mm Hg (relative risk: 2.2, 95% confidence interval: 1.136-4.423, p = 0.02). Pressures were also dependent upon the specific compression device used, with CircAid®s (35.5 mm Hg, SD: 12.0 mm Hg, n = 159) providing higher average pressures than Sigvaris Compreflex (29.5 mm Hg, SD: 7.7 mm Hg, n = 53, p = 0.009) and Sigvaris Coolflex (25.2 mm Hg, SD: 8.0 mm Hg, n = 32, p < 0.0001). These results indicate that the device-provided pressure may be dependent on both the compression device and the background and training of the applicator. We propose that standardisation in the training of compression application and increased use of a point-of-care pressure monitor may improve the consistency of applied compression, thus improving adherence to treatment and outcomes in patients with chronic venous insufficiency.

Acral Amelanotic Melanoma Mimicking a Foot Ulcer.

Acral amelanotic melanoma can be difficult to diagnose and is often clinically aggressive. The present report describes a case of an acral amelanotic melanoma presenting as a non-healing wound after mimicking a plantar wart for two years. The decision to biopsy a borderline-suspicious lesion on the lower extremity in an elderly individual must be weighed carefully, as lower extremity biopsy carries a risk of poor wound healing and other complications. We discuss clinical and epidemiologic features that can assist in deciding when to perform a biopsy in this setting and can improve the early detection of acral amelanotic melanoma.