Caring for chronic wounds

San Francisco

- Properly diagnosing the cause or causes of chronic leg wounds provides the key to treating them, though physicians sometimes neglect this step, an expert says.

"As dermatologists, we are often confronted with patients with chronic wounds, as are vascular surgeons and internal medicine specialists," says Severin Laeuchli, M.D., president of the Swiss Association for Wound Care, and a dermatologist with the University of Zürich Department of Dermatology.

He says dermatologists commonly overlook the importance of properly identifying the cause of such wounds before making treatment decisions.

However, he says, "No venous ulcer will heal if we don’t address the underlying pathology, by using compression therapy, for example."

Likewise, vasculitic ulcers won’t heal unless dermatologists prescribe immunosuppression to treat the underlying vasculitis, Dr. Laeuchli says. With vascular ulcers, he adds, it’s also important to know which vessels are and are not impacted.

Therefore, Dr. Laeuchli says, "The minimum standard diagnostic workup that we should do with every leg ulcer patient includes a basic vascular investigation," using tools such as handheld continuous-wave Doppler scanning to determine if the patient suffers from superficial venous insufficiency, deep venous insufficiency or perhaps both.

In cases of superficial venous insufficiency, he says, it is advantageous to combine compression therapy with surgical removal of the culprit vein. In the latter area, a recent 500-patient study has shown that compression alone yields a four-year recurrence rate of 56 percent, versus 30 percent for compression and saphenous surgery (Gohel HS et al. BMJ. 2007 Jul 14;335(7610):83. Epub 2007 Jun 1).

Other treatment options for venous hypertension include pharmacologic therapy and sclerotherapy.

To rule out arterial ulcers, Dr. Laeuchli recommends investigating pedal pulse, ankle systolic pressure and ankle brachial pressure index. Only selected complex cases will need measurement of toe systolic pressure and tcPO2, as well as duplex Doppler scanning and angiography.

Intervention options for arterial ulcers include vascular surgery, angioplasty, iloprost and exercise, while secondary prevention measures include controlling risk factors and perhaps using anti-thrombotic or rheologic drugs, he says.

For mixed venous-arterial ulcers, he adds, treatment begins with revascularization, followed by compression and, if indicated, saphenous surgery and, in many cases, advanced wound healing methods such as vacuum-assisted wound care (VAC) and split-thickness skin grafts.

Another key diagnostic element for nonhealing ulcers involves deciding whether biopsy and histologic analysis are indicated. "If an ulcer doesn’t heal for six months - and some experts say three months - it should be biopsied to rule out cancer," Dr. Laeuchli says.

Dermatologists also are trained to recognize rare causes for ulcers, such as pyoderma gangrenosum and infectious processes, he says.

Along with diagnosing and treating a leg ulcer’s cause or causes, successful healing requires creating optimal conditions in the local wound environment, Dr. Laeuchli says.

In this regard, he says the TIME mnemonic - tissue removal, infection control, moisture control and edge advancement - provides a useful tool. "If we address these four points, then we create a better environment for the wound to heal," Dr. Laeuchli says. DT