Effect of Povidone-iodine on Wound Healing a Review
Venous Ulcers: Diagnosis and Treatment
Am Fam Physician. 2019 Sep 1;100(5):298-305.
Patient information: See related handout on venous ulcers.
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Article Sections
- Abstract
- Pathophysiology
- Clinical Presentation and Diagnosis
- Treatment
- Prevention of Recurrence
- References
Venous ulcers are the most common blazon of chronic lower extremity ulcers, affecting i% to three% of the U.S. population. Venous hypertension as a issue of venous reflux (incompetence) or obstruction is thought to be the primary underlying mechanism for venous ulcer formation. Chance factors for the development of venous ulcers include historic period 55 years or older, family unit history of chronic venous insufficiency, higher body mass alphabetize, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of talocrural joint ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis, and venous reflux in deep veins. Poor prognostic signs for healing include ulcer duration longer than 3 months, initial ulcer length of 10 cm or more than, presence of lower limb arterial disease, avant-garde age, and elevated body mass index. On physical examination, venous ulcers are more often than not irregular and shallow with well-defined borders and are oftentimes located over bony prominences. Signs of venous disease, such as varicose veins, edema, or venous dermatitis, may exist present. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-canteen deformity of the lower leg. Chronic venous ulcers significantly touch quality of life. Astringent complications include infection and cancerous change. Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. Early venous ablation and surgical intervention to correct superficial venous reflux can meliorate healing and decrease recurrence rates.
Venous ulcers are open skin lesions that occur in an expanse affected by venous hypertension.ane The prevalence of venous ulcers in the United states ranges from ane% to three%.ii,3 In the U.s., ten% to 35% of adults take chronic venous insufficiency, and 4% of adults 65 years or older have venous ulcers.iv Take chances factors for venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or articulation disease, higher number of pregnancies, parental history of talocrural joint ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis (panniculitis that leads to pare induration or hardening, increased pigmentation, swelling, and redness), and venous reflux in deep veins.5 Poor prognostic signs for healing include ulcer duration longer than three months, ulcer length of 10 cm (3.9 in) or more, presence of lower limb arterial disease, advanced age, and elevated body mass alphabetize.6
SORT: KEY RECOMMENDATIONS FOR Exercise
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers.ane | C | Based on a clinical do guideline on disease-oriented consequence |
| Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction.1 | C | Based on a clinical do guideline on disease-oriented outcome |
| Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance.one,five | C | Based on a clinical practice guideline and clinical review on disease-oriented issue |
| Pinch therapy is beneficial for venous ulcer treatment and is the standard of care.1,28 | A | Based on a clinical exercise guideline on disease-oriented issue and systematic review of moderate-quality evidence |
| Dressings are recommended to cover venous ulcers and promote moist wound healing. No one dressing type has been shown to exist superior when used with appropriate compression therapy.one,18 | C | Based on a clinical practice guideline on illness-oriented outcome and review article |
| Pentoxifylline is effective when used as monotherapy or with compression therapy for venous ulcers.1,nineteen,39 | A | Based on a clinical practise guideline on illness-oriented outcome, commentary, and Cochrane review of randomized controlled trials |
| Early endovenous ablation to correct superficial venous reflux improves ulcer healing rates.21 | B | Based on one randomized controlled trial of more than than 400 patients |
Complications of venous ulcers include infections and skin cancers such every bit squamous cell carcinoma.seven,8 Venous ulcers are a major cause of morbidity and tin pb to high medical costs.3 Economic and personal impacts include frequent visits to health care facilities, loss of productivity, increased disability, discomfort, need for dressing changes, and recurrent hospitalizations. In one study, patients with venous ulcers used more medical resources than those without, and their annual per-patient health expenditures were increased by $vi,391 for those with Medicare and $7,030 for those with private health insurance. Employed individuals with venous ulcers missed 4 more days of work per year than those without venous ulcers (29% increase in piece of work-loss costs).9
Pathophysiology
- Abstract
- Pathophysiology
- Clinical Presentation and Diagnosis
- Handling
- Prevention of Recurrence
- References
Venous hypertension is divers equally increased venous pressure level resulting from venous reflux or obstruction. This process is thought to exist the chief underlying mechanism for ulcer formation.10 Valve dysfunction, outflow obstacle, arteriovenous malformation, and calf muscle pump failure contribute to the pathogenesis of venous hypertension.8 Factors associated with venous incompetence are age, sex, family history of varicose veins, obesity, phlebitis, previous leg injury, and prolonged continuing or sitting posture.11 Venous ulcers outcome from a complex process secondary to increased pressure (venous hypertension) and inflammation within the venous circulation, vein wall, and valve leaflet with extravasation of inflammatory cells and molecules into the interstitium.12
Clinical Presentation and Diagnosis
- Abstract
- Pathophysiology
- Clinical Presentation and Diagnosis
- Handling
- Prevention of Recurrence
- References
Clinical history, presentation, and physical examination findings help differentiate venous ulcers from other lower extremity ulcers (Table anefive). History of superficial or deep venous thrombosis, pulmonary embolism, and ulcer recurrence should be ascertained with comorbid conditions. Venous ulcers typically have an irregular shape and well-defined borders.iii Reported symptoms frequently include limb heaviness, pruritus, pain, and edema that worsens throughout the day and improves with height.5 During physical exam, signs of venous disease, such as varicose veins, edema, or venous dermatitis, may be nowadays. Other findings suggestive of venous ulcers include location over bony prominences such as the gaiter area (over the medial malleolus; Figure ane ), telangiectasias, corona phlebectatica (abnormally dilated veins around the talocrural joint and foot), atrophie blanche (atrophic, white scarring; Effigy 2 ), lipodermatosclerosis (Figure 3), and inverted champagne-bottle deformity of the lower leg.1,five
Table 1.
Common Lower Extremity Ulcers
| Ulcer type | Characteristics | Pathophysiology | Clinical features |
|---|---|---|---|
| Venous | Most common type of chronic lower extremity ulcer | Venous hypertension due to chronic venous insufficiency | Shallow, exudative ulcer with granulating base and presence of fibrin; commonly located over bony prominences such as the gaiter area (over the medial malleolus; Effigy 1) |
| Associated findings include edema, telangiectasias, corona phlebectatica, atrophie blanche (atrophic, white scarring; Figure ii), lipodermatosclerosis (Figure 3), and an inverted champagne-bottle deformity of the lower leg | |||
| Complications include venous dermatitis | |||
| Arterial | Atherosclerosis is the most common cause | Tissue ischemia | Typically, a deep ulcer located on the inductive leg, distal dorsal foot, or toes; dry, fibrous base with poor granulation tissue and eschar; exposure of tendons |
| Associated findings include aberrant distal pulses, cold extremities, and prolonged venous filling fourth dimension | |||
| Neuropathic | Well-nigh commonly a result of diabetes mellitus or neurologic disorder | Peripheral neuropathy and concomitant peripheral arterial affliction; associated foot deformities and abnormal gait with uneven distribution of human foot pressure; repetitive mechanical trauma | Deep ulcer, usually on the plantar surface over a bony prominence and surrounded by callus |
| Pressure level | Usually occurs in people with express mobility | Prolonged areas of loftier pressure and shear forces | Surface area of erythema, erosion, or ulceration; usually located over bony prominences such as the sacrum, coccyx, heels, and hips |
FIGURE ane
Venous ulcer over the medial malleolus.
Figure 2
Atrophie blanche (atrophic, white scarring) in a patient with a venous ulcer.
FIGURE 3
Lipodermatosclerosis with an inverted champagne-bottle deformity in a patient with a venous ulcer.
DIFFERENTIAL DIAGNOSIS
Although venous ulcers are the nigh common type of chronic lower extremity ulcers, the differential diagnosis should include arterial occlusive disease (or a combination of arterial and venous affliction), ulceration caused by diabetic neuropathy, malignancy, pyoderma gangrenosum, and other inflammatory ulcers.13 Among chronic ulcers refractory to vascular intervention, xx% to 23% may exist acquired past vasculitis, sickle prison cell disease, pyoderma gangrenosum, calciphylaxis, or autoimmune disease.14
Initial noninvasive imaging with comprehensive venous duplex ultrasonography, arterial pulse exam, and measurement of ankle-brachial index is recommended for all patients with suspected venous ulcers.1 Color duplex ultrasonography is recommended to assess for deep and superficial venous reflux and obstruction.1,15 Considering standard therapy for venous ulcers can be harmful in patients with ischemia, additional ultrasound evaluation to assess arterial claret flow is indicated when the ankle-brachial index is abnormal and in the presence of sure comorbid conditions such every bit diabetes mellitus, chronic kidney disease, or other weather condition that pb to vascular calcification.1 Farther evaluation with biopsy or referral to a subspecialist is warranted if ulcer healing stalls or the ulcer has an atypical appearance.1,5
Treatment
- Abstract
- Pathophysiology
- Clinical Presentation and Diagnosis
- Handling
- Prevention of Recurrence
- References
Treatment options for venous ulcers include conservative management, mechanical modalities, medications, avant-garde wound therapy, and surgical options. Although the main goal of treatment is ulcer healing, secondary goals include reduction of edema and prevention of recurrence. Table 2 includes treatment options for venous ulcers.16–22
TABLE two.
Recommended Treatment Options for Venous Ulcers
| Treatment option | Comments | |
|---|---|---|
| Conservative management | ||
| Compression therapy | Standard care; recommended for at least 1 hour per day at least 6 days per week to prevent recurrence16,17 | |
| Dressings | Recommended to cover ulcers and promote moist wound healing18 | |
| Medications | ||
| Antibiotics | Oral antibiotic treatment is warranted if infection is suspected1 | |
| Pentoxifylline | Improves healing with or without pinch therapy19 | |
| Debridement | May do good ulcer healing20 | |
| Surgical management | ||
| Endovenous ablation | Early endovenous ablation to correct superficial venous reflux may increase healing rates and forbid recurrence21 | |
| Skin grafting | Primary therapy for large ulcers (larger than 25 cmtwo [3.9 in2]) or secondary therapy for ulcers that do non heal with standard care22 | |
DEBRIDEMENT
Removal of necrotic tissue by debridement has been used to expedite wound healing. Debridement may exist sharp, enzymatic, mechanical, larval, or autolytic. Two prospective randomized controlled trials reviewed the effect of abrupt debridement on the healing of venous ulcers. Patients treated with debridement at each doctor's part visit had meaning reduction in wound size compared with those not treated with debridement.xx
Enzymatic debridement using collagenase has been shown to effectively remove nonviable tissue. There is no show that collagenase is superior to sharp debridement.23 Larval therapy using maggots is an constructive method of debridement with added potential for disinfection, stimulation of healing, and biofilm inhibition and eradication.24,25 Potential barriers to larval debridement include patient acceptability and pain.26,27 Autolytic debridement uses moisture-retentive dressings and may be used in add-on to other forms of debridement. Mechanical debridement (wet-to-dry dressings, pulsed lavage, whirlpool) has fallen out of favor.
Compression THERAPY
Pinch therapy is a standard treatment modality for initial and long-term treatment of venous ulcers in patients without concomitant arterial disease.1,28 Goals of compression therapy include reduced edema and hurting, improved venous reflux, and enhanced healing.xvi Pinch therapy is useful for ulcer healing and prevention of recurrence. Multicomponent compression systems comprised of diverse layers are more constructive than single-component systems, and elastic systems are more than constructive than nonelastic systems.28
Important barriers to the utilize of compression therapy include wound drainage, pain, awarding or donning difficulty, physical damage (weakness, obesity, decreased range of motion), and leg shape deformity (leading to compression material rolling downwards the leg or wrinkling). Contraindications to compression therapy include significant arterial insufficiency and uncompensated congestive eye failure.29
Rubberband. Elastic compression bandages conform to the size and shape of the leg, accommodate to changes in leg circumference, provide sustained compression during residue and walking, have absorptive chapters, and crave infrequent changes (about one time a calendar week).5 There is strong evidence for the apply of multiple elastic layers vs. single layers to increment ulcer healing.30
Inelastic. Inelastic compression wraps, most commonly zinc oxide–impregnated Unna boots, provide loftier compression only during ambulation and musculus wrinkle. They should not be used in nonambulatory patients or in those with arterial compromise. Unna boots accept express chapters for fluid assimilation in patients with highly exudative ulcers and are best used for early, small, dry ulcers and for venous dermatitis considering of the skin soothing effects of zinc oxide.30
Stockings. Pinch stockings can be used for ulcer healing and prevention of recurrence (recommended forcefulness is at least 20 to xxx mm Hg, only thirty to 40 mm Hg is preferred).31,32 Donning stockings over dressings tin can be challenging. Pick of knee-high, thigh-high, toes-in, or toes-out compression stockings depends on patient preference. Compression stockings are removed at night and should be replaced every six months considering of loss of pinch with regular washing. Once the ulcer has healed, connected use of pinch stockings is recommended indefinitely. For patients who have difficulty donning the stockings, apply of layered (condiment) compression stockings; stockings with a Velcro or zippered closure; or donning aids, such as a donning butler (Figure 4), may exist helpful.33
Figure 4.
Compression stocking donning butler.
Intermittent Pneumatic Compression. Intermittent pneumatic compression may be considered when there is generalized, refractory edema from venous insufficiency; lymphatic obstacle; and significant ulceration of the lower extremity. Although intermittent pneumatic compression is more than effective than no compression, its effectiveness compared with other forms of pinch is unclear. Intermittent pneumatic compression may amend ulcer healing when added to layered compression.xxx,34
LEG ELEVATION
Although leg elevation can increase deep venous flow and reduce venous force per unit area, leg elevation added to pinch may not improve ulcer healing.17 However, ane prospective study found that leg peak for at least i 60 minutes per mean solar day at least vi days per week tin reduce venous ulcer recurrence when used with compression.17,35
EXERCISE
A systematic review evaluating progressive resistance exercise, resistance exercise plus prescribed physical action, only walking, and just ankle exercises found that progressive resistance do with prescribed physical activeness may result in an additional nine to 45 venous ulcers healed per 100 patients.36
DRESSINGS
Dressings are recommended to cover ulcers and promote moist wound healing.ane,xviii Dressings should be chosen based on wound location, size, depth, moisture balance, presence of infection, allergies, comfort, odor management, ease and frequency of dressing changes, toll, and availability. Evidence has non shown that any i dressing is superior when used with appropriate pinch therapy.eighteen Types of dressings are summarized in Table 3.37
Tabular array 3.
Types of Dressings Used for Venous Ulcers
| Dressing | Characteristics | Examples |
|---|---|---|
| Absorbent | Chief or secondary dressing | Calcium alginate with or without silverish, hydrofiber with or without argent, super absorptive dressing, surgical pad |
| Cadexomer iodine (Iodosorb) | Releases complimentary iodine when exposed to wound exudate | Gel, pads |
| Capillary action | Hydrophilic fibers between low-adherent contact layers | Hydroconductive, polyester/viscose |
| Collagenase | Used in enzymatic debridement | Gel |
| Hydrocolloid | Gel-forming agents in an adhesive compound laminated onto a flexible, h2o-resistant outer motion-picture show or foam | Alginate to increment fluid absorption, with or without an adhesive border, multiple shapes and sizes |
| Hydrogels | Starch polymer and water that can absorb or rehydrate | Sheets, gel, chaplet |
| Hydrophilic polyurethane foam | Variable absorption, silicone or nonsilicone blanket | With or without an adhesive border, with or without a silicone contact layer, multiple shapes and sizes |
| Iodine-impregnated | Releases free iodine | Record, nonadherent pads |
| Depression-adherence and wound contact | Nonmedicated or medicated | Oil emulsion gauze, petrolatum gauze, petrolatum with bismuth gauze |
| Medical beloved | Possible antimicrobial and anti-inflammatory properties; absorption based on associated dressing textile or gel | Gel, paste, hydrocolloid, alginate, or adhesive cream |
| Scent absorbent | Charcoal | Flexible fiber with or without silver |
| Other antimicrobial | Chlorhexidine (Peridex), antimicrobial dyes, or hydrophobic layer | Antimicrobial dyes in a flexible or solid foam pad; hydrophobic layer available every bit a ribbon, pad, swab, or gel |
| Permeable films and membranes | Permeable to water vapor and oxygen but not to water or microorganisms | With or without an absorbent middle or adhesive edge |
| Protease-modulating matrix | Collagen | Collagen matrix dressing with or without silverish |
| Silvery-impregnated | Silvery ions (thought to be antimicrobial) | Silver hydrocolloid, argent mesh, nonadhesive, calcium alginate, other forms |
| Soft polymer | Silicone polymer in a nonadherent layer, moderately absorptive | Typically, a sheet cut to fit the wound |
Topical antiseptics, including cadexomer iodine (Iodosorb), povidone-iodine (Betadine), peroxide-based preparations, dearest-based preparations, and silver, accept been used to treat venous ulcers. Some evidence supports the utilize of cadexomer iodine to improve healing of venous ulcers, just evidence for other agents is lacking.38
MEDICATIONS
Pentoxifylline. This hemorheologic amanuensis affects microcirculation and oxygenation, and tin exist used effectively every bit monotherapy or with compression therapy for venous ulcers.1,39 In 7 randomized controlled trials, pentoxifylline plus compression improved healing of venous ulcers compared with placebo plus compression. Iv trials showed that pentoxifylline alone improved healing compared with placebo alone.19 Common agin furnishings of pentoxifylline include nausea, gastrointestinal discomfort, headaches, dizziness, and prolonged bleeding fourth dimension.
Aspirin. There is inconsistent evidence apropos the benefits and harms of oral aspirin in the handling of venous ulcers.40,41
Statins. Statins accept vasoactive and anti-inflammatory effects. In a small study, patients receiving simvastatin (Zocor), 40 mg once daily, had a higher rate of ulcer healing than matched patients given placebo.42
Phlebotonics. These venoactive drugs theoretically work by improving venous tone and decreasing capillary permeability. Common drugs in this class include saponins (due east.thou., horse chestnut seed excerpt), flavonoids (e.g., rutosides, diosmin, hesperidin), and micronized purified flavonoid fraction.43 Although phlebotonics may improve edema and other signs and symptoms of chronic venous insufficiency (due east.thou., trophic disorders, cramps, restless legs, swelling, paresthesia), at that place was no deviation in venous ulcer healing when compared with placebo.44
Antibiotics. Because bacterial colonization and infection may contribute to poor healing, systemic antibiotics are ofttimes used to treat venous ulcers. Colonization refers to the presence of replicating bacteria without a host reaction or clinical signs of infection.45 Colonized venous ulcers generally should not be treated with antibiotics. Infection occurs when microorganisms invade tissues, leading to systemic and/or local responses such as changes in exudate, increased pain, delayed healing, leukocytosis, increased erythema, or fevers and chills.46 Venous ulcers with obvious signs of infection should be treated with antibiotics. Oral antibiotics are preferred, and therapy should be express to two weeks unless evidence of wound infection persists.1
Hyperbaric Oxygen Therapy. A systematic review of hyperbaric oxygen therapy in patients with chronic wounds found only 1 trial that addressed venous ulcers. Because of express evidence and no long-term do good, hyperbaric oxygen therapy is non recommended for treatment of venous ulcers.47
Negative Force per unit area Wound Therapy. Traditional negative pressure wound therapy systems are beefy and cannot be used with pinch therapy. Negative pressure wound therapy is non recommended every bit a primary treatment of venous ulcers.48 There may be a hereafter part for newer, ultraportable, single-use systems that can be used underneath compression devices.49,50
ADVANCED THERAPIES
Venous ulcers that do not improve inside iv weeks of standard wound intendance should prompt consideration of adjunctive handling options.51
Cellular and Tissue-Based Products. There are many cellular and tissue-based products approved for the treatment of refractory venous ulcers, including allografts, fauna-derived extracellular matrix products, human-derived cellular products, and human amniotic membrane–derived products. Compared with compression plus a simple dressing, one written report showed that advanced therapies can shorten healing fourth dimension and better healing rates.52
Skin Grafting. Skin grafting should be considered as primary therapy only for large venous ulcers (larger than 25 cm2 [iii.ix in2]), in which healing is unlikely without grafting. It can be used as secondary therapy for ulcers that practise not heal with standard care.22
ENDOVENOUS INTERVENTION
Like conservative therapies, the goal of operative and endovascular management of venous ulcers (i.due east., endovenous ablation, ligation, subfascial endoscopic perforator surgery, and sclerotherapy) is to improve healing and prevent ulcer recurrence. Historically, trials comparing venous intervention plus pinch with compression alone for venous ulcers showed that surgery reduced recurrence simply did not improve healing.53 Recent trials testify faster healing of venous ulcers when early on endovenous ablation to right superficial venous reflux is performed in conjunction with compression therapy, compared with compression alone or with delayed intervention if the ulcer did non heal subsequently six months.21 The nigh common complications of endovenous ablation were pain and deep venous thrombosis.21
Prevention of Recurrence
- Abstruse
- Pathophysiology
- Clinical Presentation and Diagnosis
- Treatment
- Prevention of Recurrence
- References
The recurrence charge per unit of venous ulcers has been reported as high as 70%.35 Venous intervention and long-term use of pinch stockings are of import for preventing recurrence, and leg tiptop can be beneficial when used with compression stockings. Exercise should be encouraged to improve calf muscle pump part.35,54 Practiced social back up and self-efficacy accept also been shown to help prevent venous ulcer recurrence.35
This article updates a previous commodity on this topic by Collins and Seraj.55
Data Sources: Nosotros conducted searches in PubMed, Essential Prove Plus, the Cochrane database, and Google Scholar using the cardinal terms venous ulcers and venous stasis ulcers. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Search dates: November 12, 2018; December 27, 2018; January eight, 2019; and March 21, 2019.
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