Helping improve wound management and prevent protracted inflammation in Venous leg ulcers.

Venous leg ulcers (VLUs) affect approximately 1% of the population and are the most prevalent type of lower extremity wound.¹

For healthcare professionals, the treatment for VLUs usually includes assessing the patient and wound, identifying and addressing contributing factors and comorbidities, and creating a treatment plan, which includes skin protection, exudate management, and compression.

However, even if these steps have been followed, sometimes the VLU will not heal. In fact, studies show that only 44% of VLUs healed by week 12, while approximately 21% of VLUs never heal entirely.^2-3

Therefore, it is important to find ways to help improve patient outcomes and address the variables that might negatively affect the healing process.

Factors affecting wound management and Venous leg ulcers.

Research provides insight into which VLUs are the most challenging to heal. Healing is negatively impacted when:

• Ulcers are large or old
• There is a history of past ulcers or complicated venous disease
• There is a lack of therapeutic compression^4,5

Additional factors such as advanced age, limited mobility, poor nutrition, a history of recent hospitalization, or signs/symptoms of infection can also complicate healing.^3,4,6 None of this is a surprise to experienced wound care clinicians. But other considerations may be less obvious.

By the time most VLUs are assessed by a wound care specialist they are truly “chronic” wounds. The average age at initial assessment is five months.³ In addition to assessing and addressing the factors impacting healing mentioned earlier, it is necessary to consider the wound environment itself.

Chronic wound considerations.

“Protracted inflammation” refers to a wound that is stuck in the inflammatory phase. In a normal healing process, the inflammatory phase cleans up cellular, extra-cellular and pathogen debris and lasts 2-5 days. In chronic wounds, due to the presence of biofilm, repeated trauma, and underlying comorbidities, among other things, the inflammation continues to persist.

At a cellular level a war is raging. The body’s immune response is in action – neutrophils and macrophages are signaled. They secrete proteases (a protein-degrading enzyme), reactive oxygen species (ROS) and inflammatory cytokines.⁷ This process is essential to keeping the wound base clean and free from infection. But when prolonged, it interferes with growth factor function and degrades the extracellular matrix and healing is delayed.

Addressing protracted inflammation to help heal VLU wounds.

Incorporating these steps into your treatment plan can help the healing process of VLUs.

• Start with debridement: The body’s effort to remove of nonviable tissue, debris, and associated bacteria begins the inflammatory phase and this process continues until the wound bed is clean. Debridement of the wound as part of wound bed preparation will help assist with this process and support the transition beyond inflammation. Surgical debridement is most efficient, but depending on the clinical situation, other forms such as soft mechanical debridement or chemical debridement may be considered.
• Manage the biofilm/bioburden: The presence of bioburden or biofilm exacerbates inflammation. Since most chronic wounds are found to have biofilm, consider routine, short-term use of an antimicrobial dressing that is effective on biofilm (not just planktonic bacteria).
• Topical dressing selection: Certain types of wound dressings, such as collagen, have been found to have a positive impact on the wound environment because they help create a moist interface with the wound bed and create an environment conducive to granulation tissue development and epithelization.
• Reduce trauma: Inflammation can be triggered by recurrent trauma to the wound and surrounding tissue. In the case of VLUs, this may originate with the difficult application of compression stockings or repeated bumping of the wound area.
• Address confounding conditions: Comorbidities including diabetes and tissue hypoxia can lead to leukocyte dysfunction, creating an ineffective and prolonged inflammatory response.²

Helping to improve the healing rates of VLUs involves a comprehensive approach. Creating a plan to counter the detrimental effects of protracted inflammation is an important piece of the puzzle.

Learn more about VLU healing.

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References.

1. Harding K, et al. Simplifying venous leg ulcer management. Consensus recommendations. Wounds International 2015. Available to download from woundsinternational.com
2. Fife, C. E., Eckert, K. A., & Carter, M. J. (2018). Publicly Reported Wound Healing Rates: The Fantasy and the Reality. Advances in wound care, 7(3), 77–94. https://doi.org/10.1089/wound.2017.0743
3. Fife, C. (2018). From the Editor: The Need for Real Venous Ulcer Data. Today’s wound clinic. 12(2).
4. Parker CN, Finlayson KJ, Shuter P, Edwards HE. Risk factors for delayed healing in venous leg ulcers: a review of the literature. Int J Clin Pract. 2015;69(9):967-977. doi:10.1111/ijcp.12635
5. Fife, C. E., & Horn, S. D. (2020). The Wound Healing Index for Predicting Venous Leg Ulcer Outcome. Advances in wound care, 9(2), 68 77. https://doi.org/10.1089/wound.2019.1038
6. Parker CN, Finlayson KJ, Edwards HE. Predicting the likelihood of delayed venous leg ulcer healing and recurrence: development and reliability testing of risk assessment tools. Ostomy Wound Manage. 2017;63(10):16-33. doi: 10.25270/owm.2017.1633
7. Zhao, R., Liang, H., Clarke, E., Jackson, C., & Xue, M. (2016). Inflammation in Chronic Wounds. International journal of molecular sciences, 17(12), 2085. https://doi.org/10.3390/ijms17122085