A retrospective cohort analysis of patients' records estimated there were 2.2 million wounds in 2012/2013 in the UK, costing the NHS between £4.5 and £5.1 billion (Guest et al, 2015). Extrapolation of the data showed that almost 34% of these wounds were recorded as leg ulcers; a further 12% were unspecified wounds, which may or may not have been on the lower legs. However, population growth and healthcare costs since these data were collected means the initial estimated numbers and subsequent costs of managing wounds may be greater. Guest et al predicted that the prevalence of chronic wounds will increase by 12% per year due to delayed healing (Guest et al, 2017).
Research has shown significant inconsistencies in wound care practice including approximately 30% of wounds having no recorded differential diagnosis, and only 16% of wounds on the lower legs had a documented ankle-brachial pressure index (ABPI) (Guest et al, 2015; 2017). This suboptimal care may be contributing to delayed healing, increased risk of adverse events, and wastage of valuable resources (Andriessen et al, 2017).
When reviewing services, commissioners and managers will be promoting best practice treatment delivery that is patient-centred, effective, minimises the complications of ulceration, and eliminates, as much as possible, hospital admission (Thomas, Morgan 2017).
The literature classifies leg ulceration as either venous or arterial in origin. Nurses working with patients experiencing chronic oedema will encounter a third type of ulceration resulting from oedema. It is important to be aware of all types of ulceration, understand the need for early and accurate diagnosis, and ensure the appropriate mode of treatment is delivered to expedite healing.
Arterial ulcers
Arterial ulcers develop as a consequence of reduced arterial blood flow to the leg, the main cause of which is peripheral arterial disease (PAD). PAD affects up to 20% of the population aged 60 years and over, and incidence and prevalence increases with age, smoking, diabetes and coronary heart disease (National Institute for Health and Care Excellence (NICE) 2018).
However, approximately 50% of those with PAD have no symptoms (Dhaliwal and Mukherjee, 2007), which emphasises the need for accurate assessment before applying compression.
Arterial ulcers account for less than 1% of all ulcers (Guest et al, 2015) and often form on the outer side of the ankle, feet, or toes. They are usually deep wounds extending to underlying structures, irregular in shape with well defined margins, and have a ‘punched out’ appearance. The wound bed can appear unhealthy and they can be very painful, especially at night (Newton, 2011).
Experienced clinicians can use compression therapy to improve arterial flow and heal these ulcers but referral to a vascular team to assess the extent of disease and possibly revascularise the limb is required. It is important to stress the need to address the predisposing factors to maximise the outcomes of surgery, such as maintaining a healthy weight and dietary intake, smoking cessation, and adequate levels of exercise (Wounds UK, 2019).
Venous leg ulcers
Venous leg ulcers (VLUs) are the most common type of ulceration and they occur as a result of chronic venous disease (CVD). Superficial or perforating vein incompetence is caused by failure of the valves to prevent backflow, which increases the pressure in the veins. Valve failure can be caused by hereditary factors, varicose veins, ageing, or damage by surgery, trauma, or a deep vein thrombosis (DVT). Other factors contributing to valve incompetence include multiple pregnancies, obesity, and reduced mobility or prolonged periods of standing. Good venous return from the legs relies on a number of conditions but mainly the efficient working of the calf muscle pump, which, when activated during walking, for example, squeezes the veins to propel the contents of the veins towards the heart. Sedentary lifestyles cause a reduction in or even absence of this essential mechanism. Over time oedema, fibrosis, eczema and subsequently ulceration develops. In the majority of cases, venous ulceration develops in the gaiter area of the leg, especially around the malleolar region.
Mixed ulcers
In approximately 1% of cases, ulcers develop in the presence of both venous and arterial disease (Guest et al, 2015), highlighting the need for rigorous arterial assessment when treating leg ulcers.
Superficial ulceration
In uncontrolled chronic oedema, the swelling can cause the skin to stretch and break with fluid leaking out onto the surface of the skin (lymphorrhoea). Maceration often occurs, which leads to superficial ulceration, heavier lymphorrhoea, and increased risk of cellulitis. Unpublished audit data shows that the typical patient experiencing superficial ulceration is obese with a sedentary lifestyle, often sleeping in a chair instead of going to bed. Management of these wounds is often inadequate, resulting in prolonged nursing input lasting many months or, in some cases, years, and draining vital resources. Over time the ulceration will spread because of maceration to the peri-wound skin and patients experience pain, poor quality of life, and are often unable to leave the home.
Assessment
The presence of ulceration should prompt thorough assessment as early as possible to trigger the immediate development of an appropriate management plan (Atkin and Tickle, 2016). The assessment should incorporate the following areas.
General assessment
General assessment of past medical history, lifestyle and psychosocial issues, details of any factors contributing to or compounding the development of ulceration, and any factors inhibiting self-care such as strength or dexterity problems.
Physical examination
Physical examination of both legs, the ulcer, and the feet is essential to ascertain the aetiology of the ulcer and exclude any other local clinical issues that may require intervention such as oedema, skin changes, cellulitis, and tinea pedis. The ability to differentiate between cellulitis and other conditions that produce red and inflamed legs (such as lipodermatosclerosis, DVT, red legs syndrome) will reduce costly and unnecessary antibiotic prescribing and possible antibiotic resistance (Elwell, 2014). Limb size and shape should be recorded to provide baseline data and to determine compression hosiery size and type required if appropriate. Assessment of peripheral perfusion is an essential prerequisite of managing lower leg problems with safe levels of compression and to ensure an accurate ulcer diagnosis is reached. A hand-held Doppler can be used to calculate the ABPI as part of the standard leg ulcer assessment (Scottish Intercollegiate Guidelines Network (SIGN), 2010) and should be carried out by a competently trained practitioner (Beldon, 2010). The ABPI is derived from calculating the ratio of the highest blood pressure in the arm to the highest ankle blood pressure (Vowden and Vowden, 2001). A reading of 0.8 suggests reduced blood supply to the legs, signifying PAD (Wounds UK, 2016). It should be noted that this diagnostic test is not used to identify venous disease, its aim is to exclude arterial disease.
Systematic approach
Using a systematic approach to wound assessment with standardised tools should be normal clinical practice (Wounds UK, 2018). The assessment should include:
Using photography to capture the characteristics of the wound is considered good clinical practice but issues around consent and storage of the images must comply with local guidelines (Sperring and Baker, 2014). Comprehensively documenting the features of each wound allows accurate comparison over time and objective assessment of the progress of healing.
Diagnosis
The diagnosis will dictate the next steps in treating the ulceration. A VLU should be classified as being simple or complex to allow an appropriate level of management (Table 1).
| Simple VLU | ABPI 0.8–1.3 |
Should be managed by competent community nurses (including care home nurses) |
| Complex VLU | ABPI outside 0.8–1.3 range |
Should be managed by VLU specialist service |
ABPI=ankle brachial pressure index; VLU=venous leg ulcer
It may be appropriate to manage mixed and other arterial ulcers with compression but they should be referred to specialist vascular services for further investigation or surgical intervention (Harding et al, 2015).
A diagnosis of superficial ulceration caused by chronic oedema should trigger implementation of a suitable care pathway incorporating wound-care products and compression therapy. Using wound dressings to absorb exudate and lymphorrhoea in the absence of compression is a waste of resources and fails to promote any wound healing.
Management
Wound-bed preparation and dressing are vital components of wound management as ulcers are often characterised by moderate to severe levels of exudate and sloughy wound beds. Exudate causes maceration and further skin damage, and slough can harbour infection-producing bacteria, which prevents normal wound healing. Regular good hygiene, involving cleansing of both the wound and the surrounding skin, will remove any debris and maintain a healthy peri-wound area. Ordinary tap water can be safely used to cleanse the wound (Fletcher and Ivins, 2015) and debridement pads or exfoliating gloves are useful in the management of hyperkeratotic skin plaques and the mechanical debridement of biofilm.
Dressing prescribing will be subject to the presentation of the wound. Simple, non-adherent dressings should be prescribed to protect the wound and absorb any exudate (SIGN, 2010). However, moderate-to-high levels of exudate will require alginate, gelling fibre, or foam dressings. Debridement is necessary if the wound is sloughy and some types of dressing, such as hydrogels, will produce autolytic debridement (Harding et al, 2015).
Nurses involved in managing ulceration must be aware of the specific properties of wound dressings for use under compression therapy (Journal of Community Nursing, 2013; Harding et al, 2015). Such as dressing should:
Exudate levels may initially be high; however, successful compression therapy will improve venous and lymphatic return, resulting in reduced oedema and inflammation, and subsequently reduce the exudate (Harding et al, 2015). Frequency of dressing change should be dictated by frequency of compression bandaging application although, initially, consideration may be required for more regular changes in heavily exudating wounds. However, selection of appropriate wound dressing products should allow optimal compression delivery for up to 7 days.
In the area surrounding the ulceration there may be changes in the skin that can be local to the wound or affect the whole lower limb. The skin should be reviewed frequently for any changes and managed appropriately. Washing with soap can alter the skin's pH level, which affects the normal bacterial flora and increases the risk of colonisation by pathogenic organisms. Soap also removes the natural lipids on the skin's surface, which can irritate and dry the skin resulting in itching. Soap substitutes effectively cleanse the skin without affecting the acid mantle and causing dryness.
Emollients (available as lotions, creams and ointments) are an important aspect of promoting skin health and reducing the risk of loss of integrity (Carville et al, 2014). Emollients should be applied twice daily following bathing. They should be applied directly to the skin, and massaged in the direction of hair growth. This will help minimise the possibility of blocking the hair follicles and causing folliculitis (Penzer and Ersser, 2010). Nurses must be mindful of the pressures applied in cleansing and moisturising fragile skin as too much force may cause tears or bruising.
Dry and hyperkeratotic skin can be effectively treated by gentle exfoliation (Wounds UK, 2015). Eczema should be treated with topical steroid therapy, and compression therapy will help reduce the fibrotic skin changes (Wounds UK, 2016).
Compression therapy
The gold standard management of oedema and ulceration is the application of compression (SIGN, 2010) and should only be applied following a comprehensive assessment and by skilled practitioners. The aim of all types of compression is to reduce oedema, heal the ulceration, and reverse lymphatic and venous hypertension (Partsch and Junger, 2006).
Optimal compression therapy is applied in a graduated fashion (graduated compression), that is, the maximum pressure is exerted at the ankle and slowly reduces towards the knee.
Multi-layer compression bandaging is advocated in the management of oedema and ulceration. However, the terminology surrounding layers is questionable as there will always be some overlap when applying bandages, giving at least two layers of material at any point on the bandaged leg and therefore a single-layer bandage cannot exist. The term ‘component’ may therefore be a more accurate way to describe individual products that are used to create a compression system (World Union of Wound Healing Societies (WUWHS), 2008).
Stiff, inelastic, multi-component bandaging systems are the preferred mode of applying compression as they produce the greatest improvements in venous blood flow, and provide higher working pressures and lower resting pressures, making them more comfortable to wear (Harding et al, 2015). Multi-component compression bandage systems may contain both high-stiffness (inelastic/short-stretch) and low-stiffness (elastic/long-stretch) components. However, when applied to a leg, a multi-component system usually functions as a high-stiffness system. The individual components include a:
Additionally, compression hosiery kits (Brambilla et al, 2013), and Velcro compression wraps (NICE, 2015) can be just as effective (Adderley, 2015), although they may not be suitable for heavily exudating wounds (Journal of Community Nursing, 2013). Despite these choices, there are several factors that must be taken into consideration when prescribing compression systems (Box 2).
These considerations must include aspects of patient choice, such as ability to wear their own shoes, having minimal impact on mobility, being comfortable and being aesthetically acceptable; and should deliver clinically effective compression. Effective compression provides therapeutic levels of compression, minimal slippage, allows a good anatomical fit, and is non-allergenic (Harding et al, 2015). Skin fragility and integrity should also be considered as applying compression hosiery may cause damage or pain in some elderly patients.
Compression bandaging can remain in place for up to 7 days unless there is reduction in oedema. This change in size of the limb may cause bandaging slippage, difficulties with discomfort/pain, or exudate strikethrough, which will indicate the need for more frequent application.
Once the ulcer is healed, preventive strategies should be implemented to avoid recurrence. These should include regular monitoring and support, and prescription of compression hosiery. There is a wide range of compression hosiery available for nurses to prescribe, including compression class (British or German (RAL) standard), in various sizes, circular or flat knit, with or without toe-cap, in a variety of colours, with or without silicone bands, and ready to wear or custom made. This wide choice is helpful in considering patient choice, strength and dexterity, level of mobility, patient limb size, and skin quality.
Fitting and prescribing details can be found on the manufacturers' web pages such as at BSN Medical (http://www.bsnmedical.co.uk/bsn-medical-uk.html), Haddenham Healthcare (https://hadhealth.com/), and Sigvaris (https://www.sigvaris.com/uk/en-uk).
Including patients in the treatment decision-making process will improve concordance and reduce the cost of unused garments.
Conclusion
Chronic ulceration of the lower leg imposes significant costs in terms of NHS resources, clinician input, and patient quality of life. Patients often have to endure these wounds for months or even years because of poor clinical practice. Early identification, comprehensive assessment, accurate diagnosis, and best practice treatment can reduce the burden of cost, improve clinical outcomes, and prevent recurrence.