Management of Wounds in Patients with Lower-Extremity Venous Disease (LEVD)
1. Prior to treatment, assess causative and contributive factors and significant signs and symptoms to differentiate among the types of lower-extremity wounds, which have different etiologies and treatment requirements, in order to establish an appropriate treatment plan.(TFC, Class I, TFC)
2. Review and document the relevant health history.(Level C, Class I, Expert Opinion)
3. Assess the risks and contributing factors for developing LEVD such as family history, female sex, pregnancy, older age, tobacco use, systemic inflammation, obesity, comorbid conditions (cardiovascular disease), venous thromboembolism/ deep vein thrombosis (VTE/DVT), excessive sitting or standing, physical inactivity, trauma, injection drug use, impaired calf muscle function, and impaired ankle range of motion.(Level C, Class I, Moderate)
4. Assess the risks and contributing factors for developing a VLU, which are similar to those for LEVD: previous leg surgery, previous VLU, obesity, family history, venous reflux, VTE/DVT, physical inactivity, older age (>50 years), female sex, multiple pregnancies, and prolonged sitting or standing.(Level C, Class I, Moderate)
5. Assess for specific triggers associated with development of VLUs: cellulitis, penetrating injury/trauma, dry skin and itching, contact allergic dermatitis, rapid onset of leg edema, burns, and insect bites.(Level C, Class I, Expert Opinion)
6. Assess the history of present and prior leg ulcers: previous treatments and tolerance (eg, medications and compression), ulcer recurrences, unusual or atypical presentations of ulcers, and/or surgical interventions or biopsies.(TFC, Class I, TFC)
7. Assess for lower-extremity symptoms associated with LEVD: pain, sleep disturbances, and leg symptoms (ie, itching, heaviness, tightening, swelling, and aching).(Level C, Class I, Moderate)
8. Assess quality of life using valid/reliable instruments such as the Venous Insufficiency Epidemiologic and Economic Study (VEINES/QOL/Sym), Aberdeen Varicose Vein Questionnaire, and the Chronic Venous Insufficiency Quality of Life Questionnaire; and repeat the assessment on a regular basis.(Level C, Class I, Moderate)
9. Assess self-efficacy using a validated instrument such as the Venous Leg Ulcer Self-Efficacy Tool to determine the patient’s perception of his/her ability to perform self-management.(Level C, Class II, Expert Opinion)
10. Assess the nutritional status of the patient including intake and the availability and ability to obtain adequate food.(Level C, Class II, Low)
11. Assess biomarkers associated with risks of LEVD as appropriate: C-reactive protein, fibrinogen, interleukin-10, and interleukin-8.(Level C, Class II, Low)
12. Conduct a physical examination of the lower leg:
• Inspect the lower extremity for skin changes including hemosiderosis/hemosiderin staining, venous eczema/ dermatitis, hyperpigmentation, atrophie blanche, varicose veins, ankle flaring, scarring from previous ulcers, and lipodermatosclerosis.
• Determine the type and characteristics of lower-extremity edema to differentiate the clinical presentation of edema due to LEVD from other conditions such as lymphedema and lipedema, which may be misdiagnosed.
• Determine perfusion status:
−−Assess skin temperature (cool skin), capillary and venous refill, paresthesia, and color changes of the skin with elevation or dependency of the limb.
−−Determine presence or absence of pedal pulses. Palpate both dorsalis pedis and posterior tibial pulses of each lower extremity. Presence of palpable pulses does not rule out lower-extremity arterial disease; nor does absence of pulses indicate arterial disease, especially, in the presence of edema.
−−Perform a screening ABI to identify/rule out arterial insufficiency.
• Recheck the ABI periodically (every 3 months) for patients with nonhealing, lower-extremity ulcers.(Level C, Class I, Expert Opinion)
• Measure the skin temperature using a noncontact infrared thermometer, including areas over previously healed VLUs, to identify areas of potential inflammation or infection.(Level C, Class II, Low)
• Determine neurosensory status: Screen both feet for loss of protective sensation with a monofilament (5.07/10-g Semmes-Weinstein monofilament); check vibratory sensation with a tuning fork (128 Hz); and check the Achilles tendon reflex with a reflex percussion hammer.(Level C, Class II, Low)
• Determine the functional ability including ankle range of motion and use of any assistive devices.(Level B, Class II, Low)
13. Classify the clinical manifestations of LEVD according to the “C” component of the basic Clinical, Etiological, Anatomical, Pathophysiological (CEAP) classification.(Level C, Class I, Expert Opinion)
14. Determine and document the characteristics of the wound and periwound at each dressing change: location; size and shape; wound edges; wound bed; exudate; condition of periwound skin; and absence/presence of odor, bleeding, and complications (eg, cellulitis and eczema/dermatitis).(TFC, Class I, TFC)
15. Monitor the healing status of the wound at least weekly: Measure the percentage change in ulcer area to assess healing and determine whether adjunctive therapies are warranted for ulcers that do not heal or show significant healing within 4 weeks of appropriate treatment.(Level C, Class I, Expert Opinion)
16. Measure the ankle and calf circumference on a weekly basis to determine the effectiveness of treatments (eg, compression therapy, leg elevation, and exercise) to reduce edema.(Level C, Class I, Expert Opinion)
17. Identify factors that may impede wound healing: location, long duration, large size of the wound, comorbid conditions, suspected biofilm, inflammation, infection, lack of adherence to prevention and treatment programs (especially compression therapy), psychosocial factors including depression and social isolation, and use of medications such as steroids or long-term topical or systemic antibiotics.(Level C, Class I, Moderate)
18. Identify, monitor, and document pain in the lower-extremity and/or wound pain using a valid and reliable pain scale to determine the following: onset; duration; location; exacerbating and alleviating factors; use and response to analgesics; severity/intensity (mild to severe); characteristics of leg pain (eg, variability; stinging, throbbing, cramping, or sharp/shooting; leg heaviness and achiness; and worsens with prolonged leg dependency); and changes or alterations in pain, which may indicate a change in healing status or disease.(TFC, Class I, TFC)
19. Differentiate venous claudication from arterial, ischemic claudication:
20. Evaluate laboratory parameters such as albumin, prealbumin, hemoglobin, hematocrit, homocysteine, hemoglobin A1c (HbgA1c), prothrombin time, and inflammatory biomarkers (eg, C-reactive protein and fibrinogen) to establish potential for healing.(TFC, Class I, TFC)
21. Identify factors that are associated with VLU recurrence: long duration of a VLU, decreased physical activity, lack of leg elevation, not wearing compression, high body mass index, malnutrition, depression, low self-efficacy, and presence of comorbid conditions and other general risks for LEVD and VLUs.(Level C, Class I, Moderate)
22. Refer patients as indicated for further evaluation and diagnostic testing to determine the severity of LEVD with vascular studies such as a venous duplex ultrasound, which is the most reliable noninvasive test to diagnose anatomical and hemodynamic abnormalities, reflux, or obstruction in any venous segment (superficial and deep).(Level C, Class I, Expert Opinion)
23. Refer patients with the following conditions for further evaluation and treatment: cellulitis, VTE/DVT, variceal bleeds, intractable pain, eczema/dermatitis that is unresponsive to appropriate topical therapy and/or short-term topical steroids, and ulcers that are atypical in appearance or unresponsive to 4 weeks of appropriate therapies.(TFC, Class I, TFC)
B. Prevention and Management of LEVD and VLU Risk Reduction
24. Encourage patients to undertake a program of physical activity to strengthen the calf muscle and increase ankle range of motion.(Level C, Class II, Expert Opinion)
25. Recommend patients with varicosities wear compression stockings, manage their weight, engage in physical activity such as walking and avoid wearing constricting garments and crossing legs to reduce the risk of VLUs.(TFC, Class II, TFC)
26. Consider using the WOCN Society’s algorithm, Compression for Primary Prevention, Treatment, and Prevention of Recurrence of Venous Leg Ulcers: An Evidence-and Consensus- Based Algorithm for Care Across the Continuum (http:// vlu.wocn.org/#home), to identify the appropriate type and level of compression for adults.(Level C, Class I, Expert Opinion)
27. Screen patients for arterial disease with a Doppler measurement of the ABI by suitably trained staff prior to the use of compression.(Level C, Class I, Expert Opinion)
28. Educate individuals with sufficient blood flow (ABI ≥0.80) to use the strongest compression they can apply or tolerate to prevent VLUs or reduce recurrence.(Level A, Class I, Moderate)
29. Consider light compression for individuals with LEVD and lipodermatosclerosis, who are unable to apply, tolerate, or afford the cost of high-level compression garments.(Level B, Class I, Low)
30. Have compression stockings fitted by trained personnel.(TFC, Class I, TFC)
31. Closely supervise and monitor the use of reduced compression (23-30 mmHg) for individuals with mixed venous/ arterial insufficiency (ABI >0.50 to <0.80), which should be provided under the direction of wound care specialists.(Level C, Class I, Expert Opinion)
32. Educate patients that compression must be worn every day for the prevention of venous edema and ulceration for all CEAP classifications, and for prevention of VLU recurrence.(Level A, Class I, Moderate)
33. Avoid compression if ABI is less than 0.50, the ankle pressure is less than 70 mmHg, or the toe pressure is less than 50 mmHg; and refer the patient for further evaluation and treatment.(Level C, Class I, Expert Opinion)
34. Consider use of cryotherapy/cooling treatment to manage symptoms of LEVD.(Level B, Class II, Low)
35. Consider vein surgery or minimally invasive procedures to treat varicose veins:
• Endovascular laser ablation.
• Open surgery, endovascular surgery, or subfascial endoscopic perforator vein surgery.
36. Consider medications/supplements such as phlebotonics/flavonoids to decrease lower-extremity symptoms associated with LEVD (ie, pain, heaviness, edema, pruritus, and cramps):
• Micronized purified flavonoid fraction.(Level A, Class II, Moderate)
• Horse chestnut seed oil extract.
• Dobesilate calcium.
37. Educate patient/caregivers about risk factors and triggers for developing VLUs and self-management strategies to minimize risks: using lifelong compression; daily leg elevation; weight management; engaging in daily physical activities; maintaining a well-balanced diet; avoiding trauma; seeking professional health care for signs of increased swelling, redness, pain, or skin breakdown in the lower extremity; abnormal sensations in the skin; and medication options.(TFC, Class I, TFC)
C. Wound Management
38. Recommend patients with LEVD and lower-extremity ulcers seek care guided by a clinical wound expert.(Level C, Class I, Expert Opinion)
39. Cleanse the ulcer and periwound skin at each dressing change with a noncytotoxic cleanser (eg, potable tap water, distilled water, cooled boiled water, or saline/salt water), while minimizing trauma to the ulcer and surrounding skin ulcers. No one cleanser has been shown to be optimal for VLUs.(Level C, Class I, Expert Opinion)
40. Avoid the use of known skin irritants and allergens on the skin especially in patients with venous eczema/dermatitis because a high percentage of individuals with LEVD/ VLUs experience hypersensitivity to various ingredients and products.(TFC, Class I, TFC)
41. Patch test individuals with known sensitivities or delayed wound healing prior to use of new products.(Level C, Class II, Expert Opinion)
42. Use a topical steroid for patients with eczema/dermatitis for 1 to 2 weeks to reduce inflammation and itching, and refer to a dermatologist if the treatment is ineffective. In severe cases, a prolonged treatment with a topical steroid and/or use of systemic steroids might be warranted.(Level C, Class I, Expert Opinion)
43. Debride the ulcer to remove devitalized tissue when debridement is consistent with the patient’s condition and goals of therapy. No one method of debridement has been shown to be optimal for VLUs.(Level A, Class II, Low)
44. Consider debridement if there is a high index of suspicion that biofilm is present (ie, wound fails to heal, despite proper wound care and antimicrobial therapy).(Level C, Class II, Expert Opinion)
45. Choose the method of debridement based on an assessment of the condition of the ulcer (eg, presence or absence of infection and amount of necrotic tissue), pain tolerance, and individual circumstances such as the setting and availability of various debridement methods.(TFC, Class II, TFC)
46. Closely monitor the ulcer when any debridement method is used.(TFC, Class I, TFC)
47. Consider topical anesthetic agents to provide pain relief during debridement such as a lidocaine and prilocaine- based cream.(Level A, Class II, Moderate)
48. Select dressings according to accepted wound care principles: characteristics of the ulcer/periwound skin; level of exudate; patient needs such as comfort, cost, and ease of application; and availability of dressings. There is no one optimal type of dressing for treatment of VLUs and/or for use under compression wraps.(Level C, Class I, Expert Opinion)
49. Assess the wound at every dressing change to determine whether the type of dressing or frequency of changes should be modified.(TFC, Class I, TFC)
50. Identify and treat infection:
• Avoid the routine use of topical or systemic antibiotics in VLUs without signs of clinical infection.(Level A, Class II, High)
• Determine the bacterial bioburden by tissue biopsy or Levine quantitative swab technique when clinical symptoms of infection are present, or if biofilm is suspected due to wound deterioration or lack of healing.(Level C, Class I, Expert Opinion)
• Consider topical antibiotics for superficial infection, using culture-guided antibiotic therapy.(Level C, Class II, Expert Opinion)
−− Silver-based dressings.(Level A, Class III, Moderate)
• Treat deep tissue infection, cellulitis/advancing cellulitis, bacteremia, or sepsis with systemic, culture-guided antibiotic therapy.
51. Consider use of analgesic-containing dressings such as ibuprofen-releasing dressings to reduce wound pain.(Level B, Class III, Moderate)
52. Select the type and level of compression based on a careful assessment of the patient.(Level A, Class I, Expert Opinion)
53. Use the highest level and type of compression with which the patient will comply to promote healing of VLUs and prevent VLU recurrence taking into consideration that high compression, multicomponent systems, and compression with an elastic component may be more effective.(Level A, Class I, Moderate)
54. Have compression bandages and wraps applied by skilled personnel.(Level C, Class I, Expert Opinion)
55. Do not rely on antiembolism stockings or hose that provide low pressure (≤20 mmHg) and are not designed for therapeutic compression to prevent or treat LEVD or VLUs.(TFC, Class I, TFC)
56. Use a carefully supervised trial of modified, reduced compression bandaging (23-30 mmHg at the ankle) for individuals with mixed venous/arterial disease and moderate arterial insufficiency (ABI >0.50 to <0.80) who present with ulcers and edema.(Level C, Class II, Expert Opinion)
57. Avoid compression if the ABI is less than 0.50, the ankle pressure is less than 70 mmHg, or the toe pressure is less than 50 mmHg, and refer the patient for further testing and evaluation.(Level C, Class IV, Expert Opinion)
58. Consider using intermittent pneumatic compression for patients who have not responded to stockings/wraps, are immobile, need higher levels of compression than can be provided with stockings or wraps (ie, those with extremely large legs) or who are intolerant of stockings or wraps.(Level B, Class II, Low)
59. Monitor and reassess the use of compression on a regular basis to determine the effectiveness, patient’s tolerance and adherence, and if any complications have developed (eg, pain, pressure injury, skin irritation, and wasting of the calf muscle).(Level C, Class I, Expert Opinion)
60. Consider adjunctive therapies as indicated:
• Electrical therapy.
• Negative pressure wound therapy.(Level B, Class II, Low)
• Ultrasound (high-frequency ultrasound; noncontact low-frequency ultrasound).(Level A, Class III, Low)
61. Consider use of medications combined with usual care (eg, compression, leg elevation, and exercise) to promote ulcer healing or the rate of healing:
• Simvastatin.(Level B, Class II, Low)
• Doxycycline.(Level B, Class II, Low)
62. Refer individuals with nonhealing VLUs and suspected nutritional deficits to a registered dietitian for assessment and appropriate interventions.(Level C, Class I, Expert Opinion)
63. Consider invasive and noninvasive surgical procedures to improve VLU healing and reduce VLU recurrence:
• Subendoscopic perforator surgery.
• Skin grafts, biological dressings, and human skin equivalents:
−−Bilayered skin equivalent.
−−Human fibroblast dermal substitute.
−−Split-thickness skin grafts.
−−Hair follicle grafts.
64. Consider endovascular minimally invasive ablation of varicose veins to promote ulcer healing:
• Thermal ablation (radiofrequency, endovenous laser).(Level C, Class II, Low)
• Nonthermal ablation (foam sclerotherapy).(Level B, Class II, Moderate)
D. Patient Education and Risk Reduction Strategies for Self-management to Prevent and Treat VLUs and Prevent VLU Recurrence
65. Educate patients/caregivers about the risks, pathophysiology, disease process of LEVD, and the risks of VLUs and VLU recurrence.(TFC, Class I, TFC)
66. Utilize varied educational approaches to teach patients’ self-management including individual education and counseling, print materials, and video programs.(Level C, Class II, Low)
67. Educate the patient and caregivers in measures/strategies for self-management to reduce risks, prevent and manage VLUs, prevent VLU recurrence, and promote overall health and wellness:
• Practice good skin hygiene of the lower extremities: Use mild soap for cleansing and emollients to hydrate the skin, and avoid known sensitizing topical agents.
68. Teach patients to engage in regular and frequent exercise and physical activity, including home-based physical activity programs and resistance activities, to improve calf muscle pump function and reduce healing time.(Level A, Class II, Low)
E. Health Care Provider Follow-up
69. Regularly assess and monitor patient adherence to recommendations; for problems or complications: use of compression and the condition of stockings or bandages/ wraps; functional abilities; activities of daily living; presence of depression, sleep disturbances, and other concomitant illnesses; pain; and use and response to prescribed and self-prescribed pharmacologic agents.(TFC, Class I, TFC)
Management of Wounds in Patients with Lower-Extremity Venous Disease (LEVD)
March 1, 2020
Last Updated Month/Year
July 6, 2023
External Publication Status
Country of Publication
Female, Male, Adult, Older adult
Health Care Settings
Nurse, nurse practitioner, physician, physician assistant
Assessment and screening, Diagnosis, Prevention, Management, Treatment
D035002 - Lower Extremity, D014947 - Wounds and Injuries
lower extremity, Venous Disease, Stasis ulcer, Wounds in Patients