Management of Venous Leg Ulcers
Publication Date: August 1, 2014
Last Updated: September 2, 2022
Diagnosis
Definition
We suggest use of a standard definition of venous ulcer as an open skin lesion of the leg or foot that occurs in an area affected by venous hypertension. (BP)
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Treatment
Wound Care
Wound Cleansers
We suggest that venous leg ulcers be cleansed initially and at each dressing change with a neutral, nonirritating, nontoxic solution, performed with a minimum of chemical or mechanical trauma. (2-C)
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Débridement
We recommend that venous leg ulcers receive thorough débridement at their initial evaluation to remove obvious necrotic tissue, excessive bacterial burden, and cellular burden of dead and senescent cells. (1-B)
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We suggest that additional maintenance débridement be performed to maintain the appearance and readiness of the wound bed for healing. (2-B)
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We suggest that the health care provider choose from a number of débridement methods, including sharp, enzymatic, mechanical, biologic, and autolytic. More than one débridement method may be appropriate. (2-B)
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Anesthesia for Surgical Débridement
We recommend that local anesthesia (topical or local injection) be administered to minimize discomfort associated with surgical venous leg ulcer débridement. In selected cases, regional block or general anesthesia may be required. (1-B)
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Surgical Débridement
We recommend that surgical débridement be performed for venous leg ulcers with slough, nonviable tissue, or eschar. Serial wound assessment is important in determining the need for repeated débridement. (1-B)
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Hydrosurgical Débridement
We suggest hydrosurgical débridement as an alternative to standard surgical débridement of venous leg ulcers. (2-B)
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Ultrasonic Débridement
We suggest against ultrasonic débridement over surgical débridement in the treatment of venous leg ulcers. (2-C)
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Enzymatic Débridement
We suggest enzymatic débridement of venous leg ulcers when no clinician trained in surgical débridement is available to débride the wound. (2-C)
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We do NOT suggest enzymatic débridement over surgical débridement. (2-C)
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Biologic Débridement
We suggest that larval therapy for venous leg ulcers can be used as an alternative to surgical débridement. (2-B)
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Management of Limb Cellulitis
We recommend that cellulitis (inflammation and infection of the skin and subcutaneous tissue) surrounding the venous leg ulcer be treated with systemic gram-positive antibiotics. (1-B)
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Wound Colonization and Bacterial Biofilms
We suggest against systemic antimicrobial treatment of venous leg ulcer colonization or biofilm without clinical evidence of infection (2-C)
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Treatment of Wound Infection
We suggest that venous leg ulcers with >106 colony-forming units per gram of tissue (CFU/g) and clinical evidence of infection be treated with antimicrobial therapy. (2-C)
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We suggest antimicrobial therapy for virulent or difficult to eradicate bacteria (such as beta-hemolytic streptococci, pseudomonas, and resistant staphylococcal species) at lower levels of CFU/g. (2-C)
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We suggest a combination of mechanical disruption and antibiotic therapy as most likely to be successful in eradicating venous leg ulcer infection. (2-C)
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Systemic Antibiotics
We recommend that venous leg ulcers with clinical evidence of infection be treated with systemic antibiotics guided by sensitivities performed on wound culture. (1-C)
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Oral antibiotics are preferred initially, and the duration of antibiotic therapy should be limited to 2 weeks unless persistent evidence of wound infection is present. (1-C)
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Topical Antibiotics for Infected Wounds
We suggest against use of topical antimicrobial agents for the treatment of infected venous leg ulcers. (2-C)
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Topical Dressing Selection
We suggest applying a topical dressing that will manage venous leg ulcer exudate and maintain a moist, warm wound bed. (2-C)
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We suggest selection of a primary wound dressing that will absorb wound exudate produced by the ulcer (alginates, foams) and protect the periulcer skin. (2-B)
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Topical Dressings Containing Antimicrobials
We recommend against the routine use of topical antimicrobial-containing dressings in the treatment of noninfected venous leg ulcers. (2-A)
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Periulcer Skin Management
We suggest application of skin lubricants underneath compression to reduce dermatitis that commonly affects periulcer skin. (2-C)
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In severe cases of dermatitis associated with venous leg ulcers, we suggest topical steroids to reduce the development of secondary ulcerations and to reduce the symptoms of dermatitis. (2-C)
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Anti-inflammatory Therapies
We suggest against use of anti-inflammatory therapies for the treatment of venous leg ulcers. (2-C)
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Indications for Adjuvant Therapies
We recommend adjuvant wound therapy options for venous leg ulcers that fail to demonstrate improvement after a minimum of 4–6 weeks of standard wound therapy. (1-B)
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Split-thickness Skin Grafting
We suggest against split-thickness skin grafting as primary therapy in treatment of venous leg ulcers. (2-B)
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We suggest split-thickness skin grafting with continued compression for selected large venous leg ulcers that have failed to show signs of healing with standard care for 4–6 weeks. (2-B)
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Cellular Therapy
We suggest the use of cultured allogeneic bilayer skin replacements (with both epidermal and dermal layers) to increase the chances for healing in patients with difficult to heal venous leg ulcers in addition to compression therapy in patients who have failed to show signs of healing after standard therapy for 4–6 weeks. (2-A)
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Preparation for Cellular Therapy
We suggest a therapeutic trial of appropriate compression and wound bed moisture control before application of cellular therapy. (2-C)
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We recommend that adequate wound bed preparation, including complete removal of slough, debris, and any necrotic tissue, be completed before the application of a bilayered cellular graft. (1-C)
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We recommend additional evaluation and management of increased bioburden levels before the application of cellular therapy. (1-C)
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Frequency of Cellular Therapy Application
We suggest reapplication of cellular therapy as long as the venous leg ulcer continues to respond on the basis of wound documentation. (2-C)
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Tissue Matrices, Human Tissues, or Other Skin Substitutes
We suggest the use of a porcine small intestinal submucosal tissue construct in addition to compression therapy for the treatment of venous leg ulcers that have failed to show signs of healing after standard therapy for 4–6 weeks. (2-B)
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Negative Pressure Therapy
We suggest against routine primary use of negative pressure wound therapy for venous leg ulcers. (2-C)
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Electrical Stimulation
We suggest against electrical stimulation therapy for venous leg ulcers. (2-C)
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Ultrasound Therapy
We suggest against routine ultrasound therapy for venous leg ulcers. (2-B)
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Overview
Title
Management of Venous Leg Ulcers
Authoring Organizations
American Venous Forum
Society for Vascular Surgery