A venous leg ulcer (VLU) is an open lesion usually on the medial side of the leg between the knee and ankle joint that occurs in the presence of chronic venous disease and takes more than 2 weeks to heal (Harding et al, 2015; National Institute of Health and Care Excellence (NICE), 2017). Various time periods are used to define ‘chronic’ but, because of the need to expedite accurate diagnosis and appropriate interventions, NICE (2017) advocates the 2-week definition.
Ulceration is caused by sustained venous hypertension as the result of chronic venous insufficiency and/or an impaired calf muscle pump, and often presents with associated chronic fibrotic and inflammatory skin changes, and chronic oedema (Scottish Intercollegiate Guidelines Network (SIGN), 2010; Agale, 2013). The ulcer may be the result of mild trauma to the area and, because of the prolonged reduction in oxygen and nutrients being supplied to the skin, the healing process is delayed (Spiridon and Corduneanu, 2017).
It is well documented that the prevalence of VLU is increasing, which is linked to the ageing population. Chronic venous ulceration is estimated to affect 0.6-3% of people aged >60 years, rising to more than 5% of those aged >80 years (Agale, 2013). More recently, researchers demonstrated that 1.5% of the adult population (700 000) had an active ulcer in the study year, resulting in a significant economic burden to the NHS (Guest et al, 2015). It is estimated that the population aged >85 years will rise year on year and by as much as 144% between 2010 and 2031 (Scottish Government, 2010), so the incidence of VLU is also expected to rise. Furthermore, many older patients have comorbidities that compound the problem by reducing mobility, such as arthritis, obesity and respiratory disease. Immobility affects calf muscle activation so can result in venous hypertension (Wounds UK, 2016).
The clinical picture of chronic VLUs is often one of cyclical ulceration, healing and recurrence (SIGN, 2010; Wounds UK, 2016). Healing rates of VLUs vary, depending on treatment. Specialist clinics have achieved 6-month healing rates of 69-74% compared to approximately 20-34% in community treatment centres (SIGN, 2010); healing rates can be improved if best practice is implemented when delivering care (Royal College of Nursing, 2008). Despite this, in patients where healing is achieved, there are 12-month recurrence rates of 18-69% (Nelson and Bell-Syer, 2012; Ashby et al, 2014) and recurrence rates are higher in people from lower socioeconomic groups. This means many patients will have to endure ulceration for the biggest part of the remainder of their lives. This gloomy picture compounds the physical, psychological and social impact of ulceration.
Chronic oedema is not a purely inherited condition; it results from other predisposing factors that lead to lymphatic failure (British Lymphology Society, 2016). For example, it can result from chronic venous disease, prolonged dependency of the limbs, immobility, obesity or chronic organ failure (cardiac or renal, for example). Other dependent parts of the body can be affected, such as a large, pendulous abdomen in patients who are obese, or dependent flail arms following stroke. The chronic swelling is often accompanied by skin changes such as hyperkeratosis, fibrosis, chronic inflammation and lymphorrhoea (wet legs), and there is an increased risk of cellulitis developing (International Lymphoedema Framework, 2006). In 40% of cases of chronic oedema, there is a concurrent leg ulcer (Moffatt et al, 2017).
It has been estimated that chronic oedema affects 3.99 per 1000 people in the UK, which increases with age to 10.31 per 1000 people over 65 years and 28.57 per 1000 of those aged over 85 years (Moffatt et al, 2017). Women are affected more than men, at 5.37 per 1000 compared with 2.48 per 1000 of men (Moffatt et al, 2017).
There are several risk factors for developing VLU and/or chronic oedema (Box 1), many of which can be avoided (NHS, 2019). The typical patient with wet legs and ulceration in chronic oedema tends to be morbidly obese with low levels of activity and prolonged periods of leg dependency (Humphreys et al, 2017).
Managing and living with VLUs, chronic oedema, wet legs and superficial ulceration is costly in terms of resources, hospital admission, nurses' time and effects on patients' quality of life (QoL) (Humphreys et al, 2017).
Unfortunately, patients can be managed inappropriately in the community through the use of dressings alone, without the application of compression therapy. This can continue for months or even years and provide only short-lived improvement in symptoms. The cost of managing each of these patients in a 3-month period has been estimated to be approximately £5870 (Humphreys et al, 2017). Nurses often become frustrated or disillusioned at the protracted duration of care and the lack of measurable outcomes.
The chronicity of VLUs in terms of healing rates, duration and recurrence rates means that their treatment and associated comorbidity cost the NHS approximately £400 million per year; however, this is thought to be grossly underestimated as Guest et al (2015) extrapolated from their retrospective cohort analysis of 1000 patient records that the NHS manages almost 700 000 leg ulcers per annum, equating to 32% of all chronic wounds. Their calculation of the cost of these chronic wounds and their associated comorbidities is £5.3 billion; 32% of this is £1.69 billion. The long-term physical, psychological, and social costs to patients with VLUs and/or chronic oedema are just as staggering. Table 1 highlights the similarities experienced by both patient groups (Vishwanath, 2014; Cooper, 2018).
| Effects of VLUs on quality of life (QoL) | Effects of chronic oedema on QoL |
|---|---|
|
Physical Difficulty with clothing and footwear, reduced mobility, pain, malodorous exudate, itch, frequent clinic/community nurse appointments, wound dressings/compression |
Physical Difficulty with clothing and footwear, heavy limbs, reduced mobility, pain, malodorous exudate, itch, frequent clinic/community nurse appointments, wound dressings/compression |
Considering the immense human and financial costs of managing and living with these conditions, it is important to implement more rigorous preventative strategies including avoiding as many risk factors as possible. For patients at risk, compression can prevent ulcers and oedema from developing and will be more cost-effective than treating chronic ulceration and/or swelling, as well as any associated comorbidity. It is important to note that attempting lifestyle changes in the presence of ulceration and/or swelling is difficult because of the conditions' physical and psychological impact.
Selective compression bandaging in VLU/chronic oedema management
Treatment of VLU and chronic oedema should be preceded by a thorough assessment leading to an accurate diagnosis of the underlying pathophysiology and identification of any contraindications to compression. For example, arterial status can be assessed using Doppler and calculation of ankle-brachial pressure index (ABPI) (Wounds UK, 2016; NICE, 2017).
The linchpin of the management of VLU/chronic oedema is compression therapy and this should be started as early as possible (Wounds UK, 2016) to promote healing, reduce swelling and prevent progression of the condition. Compression achieves this by creating a firm support around the limb, which helps to improve lymphatic return, assists the action of the calf muscle, and prevents venous dilatation during walking or standing (Partsch and Jünger, 2006). Increased blood flow improves the supply of nutrients to the skin, which speeds up healing and reduces inflammation, and capillary filtration is decreased, which reduces lymphatic load.
Compression bandaging systems usually have 2–4 components and may include both high stiffness and low stiffness bandages (Harding et al, 2015). However, when applied to a leg, a multicomponent system usually functions as a high stiffness system. The term multilayer bandaging has been preferred in the literature and in practice but, as there will always be some overlap when applying bandages, with at least two layers of material at any point on the bandaged leg, a single-layer bandage cannot exist. The term component may therefore be a more accurate way to describe the individual products that are used to create a compression system (World Union of Wound Healing Societies, 2008).
Stiff, inelastic, multicomponent 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). Other compression systems available to manage VLU and chronic oedema include hosiery kits and adjustable compression wraps, which are more cost-effective and allow greater self-care but are not suitable in the presence of heavily exuding ulceration, fragile and vulnerable skin, if the patient has dexterity and strength issues, and if limb shape is poor (Harding et al, 2015).
Undergoing compression bandaging can be challenging for patients. Bandages can become wet during bathing and showering despite the array of products available to keep them dry. They can be uncomfortable to wear, be too warm in bed and affect being able to wear normal footwear, and many patients complain of pain and itch; all of these affect lifestyle (Edwards, 2003). If compliance with treatment are to be achieved, the compression system should (Harding et al, 2015):
AndoFlex TLC Calamine kit
AndoFlex TLC Calamine is a two-step, short-stretch, moisture-resistant controlled compression system with the soothing benefits of calamine. Calamine is a combination of zinc oxide and 0.5% ferrous oxide, and can contain additional ingredients such as phenol and calcium hydroxide. Along with the itch-relieving properties, these ingredients have antiseptic and antibacterial properties, and aid the healing of superficial wounds.
Visual indicators are provided for ease of application—ovals become circles when intended compression is achieved, and HandTear technology means scissors are not needed for removal. The minimal bulk of the bandaging and the lightweight stocking allows patients to wear their own shoes without difficulty and AndoFlex TLC prevents sticking to clothing.
Contents
Each AndoFlex TLC Calamine kit contains:
A nylon stocking is included. This is applied over the completed bandage for patient comfort and ease of movement under clothes and on bed clothes.
The kit is available in Lite compression for patients with an ABPI of ≥0.5, providing 25–30 mmHg pressure at the ankle, and standard compression for those with an ABPI of ≥0.8, providing 35-40 mmHg pressure at the ankle.
Advantages
The advantages of the AndoFlex TLC Calamine kit include:
Trials of AndoFlex TLC Calamine
Clinical trials have been carried out using the two-layer zinc and calamine impregnated bandage system (Lullove and El-Tahlawy, 2012). Eight wound care centres in the US compared comfort and healing results of the new bandage system with the results of Unna boot treatment in the same patients. The results provide ‘overwhelming improvements’ in the following aspects:
The study also found that treatment time was reduced and both clinicians and patients preferred the new bandage system.
Clinician testimonials include:
‘Please send more TLC Calamine Unna boots. The results are very good. I'd like to introduce to my product committee for our six health systems … get on formulary.’
‘The patient was pleased when she saw how much oedema was reduced. The TLC Calamine is easy to apply and provides good compression and immediate comfort.’
‘We, as well as our patients, are pleased with the TLC Calamine—the patients state it's comfortable … doesn't slip down or bind at the ankle.’
‘We wrapped a patient with the TLC Calamine – he returned today and gave us a ‘thumbs up’. He said that for the first time, it felt great and he didn't experience any pain. His leg looks wonderful, with wound improvement and decreased oedema. We're very pleased, (caring for) this patient has been challenging.’
Case study
Mr P is an 81-year-old man with chronic oedema in both lower legs with associated ulceration, significant exudate and inflammatory skin changes (Figure 1). He had been treated in the community for 4 years with no improvement in the symptoms. His treatment consisted of wound dressings without compression.
Following assessment at lymphoedema services, he was started on a course of compression bandaging, with wound dressings to ulcerated areas. While the compression improved the swelling and ulceration, it exacerbated the itch in his legs, and this caused him to push the bandaging down and scratch his legs, resulting in further skin breakdown.
The ulcers were healed after several months of bandaging but the skin was too vulnerable to allow compression hosiery to be fitted. Long-term weekly bandaging was carried out and, although this was time-consuming for Mr P, it was preferable to the wet legs he had experienced in the past.
AndoFlex TLC Calamine was tried to relieve the itch and allow normal footwear, which is often not possible when bulkier compression systems are applied.
In one week, the inflammation had resolved, and there was no itch (Figure 2). Mr P had not been itch-free before and was so keen to continue with this bandaging that he purchased the kit himself until his GP could prescribe it. His skin is still not ready to allow compression hosiery to be fitted but it is hoped that this will happen soon.
Conclusion
Managing venous ulceration and oedema is time-consuming and costly. For the patient, these conditions could mean a lifetime of cyclical healing and wound breakdown, with chronic issues with pain, itch, uncomfortable and inconvenient treatment, and clothing and footwear problems.
Providing treatment that helps to alleviate these problems is paramount for nurses delivering care to this patient group. AndoFlex TLC has been shown to deliver on all of the issues that affect both patients and clinicians resulting in less symptoms, improved healing, and reduced clinician time.