Venous ulcer care

Joel Arudchelvam
GC Fernando
ISBN - 978-624-96660-0-9

Printed By
New Karunadhara Press
Colombo 10
 Preface

Varicose vein and venous ulcers are common problems.

Most of the long term wounds presenting to a clinic is due to venous
disease. In the process of healing these ulcers, the patient has to
understand and follow many things. Following the instructions given
by the health staff is extremely important in healing these wounds.
But in day to day practice I have noticed that information given
to the patient at the time of a busy clinic is often too much for the
patient and difficult to understand. Therefore I thought of including
these instructions and information with the medical background
in a booklet, Which the patient can read leisurely at home and
understand. And I hope this booklet will improve the understanding
and compliance of the patient, resulting in improved wound healing
and patient satisfaction.

Thank you
“Vidya Nidhi” Dr. Joel Arudchelvam
MBBS (Col), MD (Sur), MRCS ( Eng)
Consultant Vascular and Transplant Surgeon
What are varicose veins

Varicose veins are enlarged tortuous superficial veins. This

usually occurs in the lower Limb (leg). But it can also occur in other
parts of the body due to unusual reasons.

Figure 1 Varicose veins

2 Venous ulcer care
Veins of the lower limb (leg)

The blood is pumped from the heart and enters the lower limbs
through the arteries. Then the blood in the leg is drained back into
the heart through the veins. That means within the veins the blood
flows towards the heart. This uni-directional flow is maintained by
the valves in the veins.

There are two types of veins in the leg. One type of vein is in the
subcutaneous tissues (under the skin). These are called the superficial
veins (the Great Saphenous Vein - GSV and the Short Saphenous
Vein - SSV - Refer the diagram). The great saphenous vein and short
saphenous vein are called major truncal veins. The other types of
veins are deep to the fascia of the leg (fascia is a thick layer of sheet-
like tissue that covers the muscles and the deep blood vessels of the
lower limb). These veins are called the deep veins (e.g. Femoral vein ,
Popliteal vein - Refer diagram).

Figure 2 Veins of the lower limb

Venous ulcer care 3
 Figure 3 Deep and Superficial veins

The muscles of the foot and the calf help to pump the blood in the
deep veins towards the heart.These are called foot and calf muscle
pumps.

When there is a weakness in the wall or the valves of the vein, they
do not function properly,and the blood in the vein flows backwards
towards the foot, instead of travelling towards the heart. This is called
venous reflux. This results in pooling of the blood within the veins,
which in turn results in distension of the veins and an increase in
the pressure within the veins (venous hypertension). In addition the
veins becomes elongated and tortuous (varicose veins).

When varicose veins develop as a result of weakness of the vein

wall or as a result of dysfunctioning valves as described above it is
called the primary varicose veins. When there is a block in the vein
either due to a clot (venous thrombosis) or due to other reasons
( due to past injuries ), the blood flow within the vein is obstructed
and the vein becomes distended and turns into a varicose vein. Also
the pressure within the vein increases. This kind of varicose vein is
called the secondary varicose vein.

4 Venous ulcer care

What are ulcers or wounds?
Ulcers or wounds are defined as disruption of the continuity of the
skin. When a wound occurs, there are sequential events which result
in wound healing. These events are well coordinated by the body.
For proper wound healing the local conditions on the wound,
the regional conditions of the leg and the systemic conditions of the
body should be perfect.
Most ulcers heal with minimal treatment, but some ulcers need
intensive treatment. But some ulcers do not heal even with intensive
treatments. When ulcers do not show any signs of healing by six
weeks it is called a chronic ulcer.
Chronic ulcers are present in 1 to 3% of the population all around
the world. 70% of the chronic ulcers are caused by the chronic venous
diseases like varicose veins. Chronic ulcers affect the quality of life
of the patient in many ways.Management of chronic venous ulcers
causes huge economic burden worldwide.
The causes for non healing ulcers include the following;
As mentioned earlier for the proper wound healing local
conditions, regional conditions and systemic conditions of the patient
contributes. Therefore when there are problems in these factors the
wounds do not heal properly e.g.
◆ Poor local conditions like infection, presence of foreign body
etc.
◆ Regional conditions ( in the leg) like reduced blood supply
due to arterial occlusion, chronic venous disorders like
varicose veins and nerve abnormalities like neuropathy
resulting in lack of sensation ( common in patients with
diabetes mellitus).
◆ Systemic conditions like anaemia, protein deficiency, diabetes
mellitus, liver and renal failure, etc also results in poor wound
healing.

Venous ulcer care 5

 In patients with chronic venous disorders and varicose veins, the
increased pressure within the veins leads to leakage of fluid from the
blood vessels. This causes swelling of the leg ( leg edema).
Also due to venous hypertension the proteins e.g.fibrin, leak out
of the capillaries. This protein forms a cuff around the capillaries.
This results in reduced nutrition and oxygen diffusion to the skin
and the ulcer.
In addition the white blood cells in the blood stick to the vein
wall due to slow flow in the varicose veins. These white cells release
substances that damage the blood vessel wall.
Due to these changes the tissues of the skin become thickened
(lipodermatosclerosis) and fibrosed especially in the lower leg
resulting in contraction of the size of the lower leg.
And also the red blood cells leak into the tissues. These are
turned into pigments which results in dark discoloration of the skin
( Pigmentation).
The valves in the varicose veins do not function properly and the
blood refluxes backwards towards the leg. This additional refluxing
blood has to be pumped by the calf muscles back towards the heart,
therefore there is increased work for the calf muscles. This causes the
calf muscles to become larger.
Also due to the contraction of the lower leg and enlargement of
the calf muscles the leg take a particular shape (figure ). The leg will
look like a wine glass ( Champagne glass ).
As a result of these changes in patients with varicose veins, the
skin becomes easily ulcerated and does not heal properly.

6 Venous ulcer care

 Figure 4 Champagne glass

Figure 5 Champagne glass appearance of leg

Usually the ulcers due to varicose veins occur in the lower leg over
the malleolar area ( Bony prominences at the ankle joint). This is also
called the “gaiter area” ( refer the diagram).

Venous ulcer care 7

 Figure 6 venous ulcer in Gaiter area

Venous ulcers are usually shallow, and the base of the wound is flat
and covered with pink colour (granulation) tissue. The venous ulcers
are usually oozy (lots of fluid leak out from the wound) due to the
presence of venous hypertension and leg edema. Venous ulcers are
usually painless. But some can have little pain.

8 Venous ulcer care

How does an infected ulcer look like?
As mentioned earlier the venous ulcers usually have a flat base
with pink colour granulation tissue on it. But there may be a small
amount of yellow coloured substance on the wound (slough). But
this does not mean that the wound is infected. But this slough needs
to be removed to allow the growth of healthy granulation tissue and
wound healing. Your doctor usually removes the slough when the
dressings are changed. When a venous ulcer becomes infected it
becomes painful, and there may be foul-smelling more than usual
amount of discharge from the wound, and the surrounding leg
becomes warm and swollen. You may develop fever. When there are
above mentioned signs of infection you need to consult your doctor
and you need to take antibiotics. There is no need for long term
antibiotics for venous ulcers. Antibiotics will not cure the wound.
But if you develop recurrent infections, your doctor will decide on
the need for long-term antibiotics.

How venous ulcers are treated

Venous ulcers do not heal like the other ulcers due to the
presence of venous hypertension, edema and skin changes e.g.
lipodermatosclerosis. To counteract this, the mainstay of treatment
of venous ulcer is multi layered bandage dressing. This is also called
strapping. Multilayer dressing is aimed at counteracting the effects of
venous hypertension.
Usually in multilayer dressing the following layers are applied;
◆ A dressing over the wound ( usually a Vaseline tulle and gauze
swab),
◆ A layer of cotton wool
◆ A layer of Crepe bandage. When the Crepe bandage is applied it
is applied firmly with maximum firmness / pressure in the foot
and as the bandage is applied to the leg the firmness is

Venous ulcer care 9

 gradually reduced (graduated compression). The aim of applying
the crepe bandage in such a way is to promote the drainage of
blood from the foot to the calf and subsequently to your heart.
Therefore the effects of venous hypertension and blood pooling
in the leg are reduced. This results in reduction in leg swelling
and reduction in oozing of fluid from the wound. This promotes
wound healing.

◆ Another layer of adhesive plaster and a cohesive bandage may

be applied in some patients. There are commercially made four
layered compression dressings available.

Figure 7 Cotton wool

10 Venous ulcer care

Figure 8 Crepe bandage

Figure 9 Elasto plaster

Venous ulcer care 11

 Figure 10 Cohesive bandage

Usually this compression bandage can be kept for a week. But

initially in some patients there may be a lot of oozing. Therefore
the dressings needs to be applied twice a week. There is no need to
change the dressings daily unless it is getting soaked daily.
As mentioned earlier the compression bandage is applied firmly,
but too tight dressing will reduce the blood supply to your leg and
cause harm. Therefore you must report to your doctor if you feel that
the dressing is too tight or if you get swelling or pain on the toes.
If these things occur, you are advised to remove your compression
dressing at home and report to your doctor.
In addition to applying the compression dressing, you are advised
to keep your leg elevated whenever possible. elevating the feet above
the heart level results in easier drainage of the blood within the

12 Venous ulcer care

leg towards the heart. This in turn reduces the pooling of blood in
the leg and the venous hypertension. You can elevate your feet by
following ways;

◆ When you are sleeping you can raise the foot end of the bed
by keeping a log or brick under the legs of the bed (Refer
diagram).

◆ You can also elevate your feet by keeping two pillows under
the leg or under the mattress. Keeping the pillows under the
mattress is a better mode of elevation rather than keeping it
under the legs. Because the feet may slip from the pillow when
you are asleep.

Figure 11 Methods of leg elevation 1

Figure 12 Methods of leg elevation 2

Venous ulcer care 13
 By using whatever the above mentioned methods, you are
supposed to raise the feet by at least 6 inches for the elevation to be
effective.
When you are seated you can keep another chair in front and keep
your affected leg elevated.
Your doctor may also prescribe a diuretic (a drug which increases
the urine flow) to reduce the leg edema.
You can also learn to do the technique of proper strapping from
your doctor or a nurse

What are the investigations done in case of venous

ulcers?

Figure 13 Duplex scan

Your doctor will do an ultrasound scan of your leg to confirm
the presence of underlying varicose veins, especially in a patient with
leg edema where the superficial veins are not easily visible. And also
the scan will help to identify the main venous trunk involved (e.g.
Great Saphenous Vein or Short Saphenous Vein ) and the refluxing
superficial branches ( refer diagram) . And by using ultrasound scan
the status of your deep veins are also assessed ( presence of deep
14 Venous ulcer care
venous reflux or thrombosis ). And he will prescribe the appropriate
treatment for the varicose veins.

What are the treatment options for venous ulcers?

Generally when the patient has Great Saphenous Vein reflux, either
an Endovenous LASER treatment or Sapheno Femoral Junction
ligation (SFL) and stripping of the Great Saphenous Vein is offered.
In Endovenous LASER ablation (EVLA) the patient is given a local
anesthesia to the leg and the LASER wire is inserted into the vein.
The LASER creates heat which results in clotting and destruction
of the varicose vein. This is a single day procedure and you can go
home on the same day. In Sapheno Femoral Junction Ligation (SFL)
you are given a spinal anesthesia.In the groin area a small cut is made
and the vein is tied. A wire (Stripper) is inserted into the vein and
the vein is removed. For this procedure you have to stay in the ward
for at least two days.
When there is a Short Saphenous Vein reflux, again either
endovenous laser ablation or Sapheno Popliteal Junction Ligation
(SPL) is offered .Endovenous LASER ablation is done under local
anaesthesia and you can go home on the same day. SPL is done under
either the local anaesthesia or spinal anaesthesia. If it is done under
spinal anaesthesia you have to stay in the ward for at least two days.
During SPL a small cut is made behind your knee joint, and the vein
is identified and tied.
When there is reflux in non major truncal veins sclerotherapy
or avulsion of the veins is offered. For sclerotherapy a drug (Sodium
Tetradecyl sulphate / STD) is made into a form (as shown in the
image below) and injected directly into the varicose vein with a small
needle. This will result in clotting of the vein and subsequent cure.

Venous ulcer care 15

For deep vein reflux multi layered bandaging is the main treatment.

Figure 14 LASER machine and fibre

Figure 15 Sclerosant and Foam

16 Venous ulcer care

 Only very few patients with very large ulcers need skin grafting.
Your doctor will let you know whether you need skin grafting.
After the ulcer has healed your doctor will prescribe compression
stocking for you. It is essential to wear this while you are standing (i.e.
during the daytime). Because even if your varicose veins are treated,
some people have abnormalities in the deep veins which will result in
the ulcer appearing again.

How do I take a bath? Can I wet the dressing?

You cannot wet the compression dressing because it will become
hard and tight. If you want to take a bath you can either do it after
removing the compression dressing and take a bath immediately
and re apply the compression dressing or you can apply a large
impermeable bag (polythene bag) to the leg and apply a plaster to the
top of the bag to prevent water getting in and then take a bath while
keeping the leg elevated (on a chair or any other object). In any case
if the dressing gets wet it needs to be changed.

Figure 16 how to protect the dressings when having a bath

Venous ulcer care 17

Will I need a surgical wound cleaning?
The wounds due to varicose veins are often clean. Therefore wound
toilets or surgical wound cleaning are rarely done. However in some
patients, there is a lot of yellow colour unhealthy substance on the
wound or there may be an underlying collection of pus especially in
patients with diabetes mellitus. In these situations your doctor may
decide to perform a surgical wound cleaning and pus drainage.

Are there any special dressings to heal the venous

ulcers?
A “wound dressing” is a material applied directly on the wound.
The material which directly touches the wound is called the primary
dressing. And additional layers applied over the primary dressing
are called secondary dressings. For example in multilayer bandages,
the material applied directly on the wound e.g. vaseline tulle, is the
primary dressing and the cotton wool, the crepe bandage and the
other layers of bandages are secondary dressings.

The following functions are expected from a good wound dressing;

◆ Covering and protecting the wound
◆ Absorption of fluid exuding from the wound.
◆ Maintaining the moisture in case of dry wounds, and aiding
the enzymatic lysis (natural mechanism of removal of dead
tissues from the wound).
◆ Killing the microbes in the wound
◆ In addition the dressing used should not be expensive and
freely available.
◆ The dressing should not cause pain or damage the wound
when it is removed (for example if the dressing is too sticky it
will damage the newly formed epithelium on removal).

18 Venous ulcer care

 There are various commercially available dressings serving some
of these purposes. For example “foam” dressings (refer diagram)
absorb fluid exuding from the wound. And gel dressings maintain the
moisture on the wound. Maintaining the moisture on the wound is
important to facilitate the wound healing and to facilitate the natural
enzymatic lysis of slough. And silver dressings help in killing the
microbes on the wound. This can be used in infected wounds. The
commonly used vaseline tulle dressing does not stick to the wound.
Therefore the pain is less while removing the dressings.

Figure 17 Foam Dressing

Figure 18 Gel Dressing

Venous ulcer care 19
 Figure 19 Silver Dressing

Figure 20 Vaseline Gauze Dressing

20 Venous ulcer care

 As explained, the venous ulcers occur due to venous hypertension
and its complications i.e leg edema, skin thickening and micro
vascular changes resulting in reduced nutrition and oxygen supply
to the wound. Correction of these abnormalities with multi-layered
compression bandages is the only effective method of treatment.
This will counteract the abnormalities arising as a result of venous
hypertension. Any form of dressing without compression will not be
effective.
However depending on the local conditions of the wound, for
example in the presence of oozing of fluid from the wound, local
infection, the doctor may decide to use a few special forms of
commercially available dressings.
In addition, treating other conditions you have is very important.
For example if you have uncontrolled diabetes mellitus, you have a
high chance of getting the wound infected which will result in delayed
wound healing and serious consequences to your body. Also if you do
not take a healthy meal containing adequate protein and minerals the
resulting low protein levels and low hemoglobin level ( anaemia) will
slow the wound healing. In addition increasing body fat especially
the fat in the abdomen increases the venous pressure and worsens the
effects of venous hypertension. Therefore maintaining a healthy body
weight is important.

Venous ulcer care 21

In summary

◆ Varicose veins and venous hypertension cause non healing

ulcers.
◆ Multi layered compression bandages, elevation and treatment
of underlying venous abnormalities are the mainstay of
treatment.
◆ Patients’ commitment and compliance with the instructions
given by all the medical staff are also very essential to cure the
ulcer.

If you have any questions or suggestions you can contact through

the following email address:
joelaru@yahoo.com

[All images were drawn and photographs were taken and edited by
Joel Arudchelvam.]

22 Venous ulcer care

ISBN- 978-624-96660-0-9

Price Rs. 200/=