Lower Extremity Ulcer

8/12/2019 Lower Extremity Ulcer

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LowerExtremity

UlcerBagus Andi PramonoSupervisors:

dr. Hariadi Hariawan, SpPD, SpJPK

Dr. dr. Budi Yuli Setianto, SpPDK, SpJPK


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Background

Chronic ulceration of the lower leg is a frequent condition,with a prevalence of 35% in the population over 65 years ofage.

The incidence of ulceration is rising as a result of the ageingpopulation and increased risk factors for atheroscleroticocclusion such as smoking, obesity and diabetes.

A leg ulcer is a loss of skin below the knee in the leg or foot which takesmore than 4 - 6 weeks to heal

Mekkes et al., 2003


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Background An appreciation of evidence-based treatment pathways

and an understanding of the pathophysiology of chronicwounds are important elements in the management ofpatients with chronic wounds

Vascular contribution in ulcer pathogenesis


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Common causes Venous insufficiency (post-thrombotic syndrome)

Peripheral arterial disease (arteriosclerosis)

Diabetes (neuropathy and or arterial occlusion)

Decubitus (pressure) Infection (mostly Streptococcus haemolyticus)

Vasculitis (small vessel leucocytoclastic vasculitis)

Mekkes et al., 2003


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Leg ulcers Causes Poor circulation, often caused by arteriosclerosis

Venous insufficiency (a failure of the valves in the veins of the leg that

causes congestion and slowing of blood circulation in the veins)

Other disorders of clotting and circulation that may or may not be related

to atherosclerosis

Diabetes

Renal (kidney) failure

Hypertension (treated or untreated)

Lymphedema (a buildup of fluid that causes swelling in the legs or feet)

Inflammatory diseases including vasculitis, lupus, scleroderma or other

rheumatological conditions

Other medical conditions such as high cholesterol, heart disease, high

blood pressure, sickle cell anemia, bowel disorders History of smoking (either current or past)

Pressure caused by lying in one position for too long

Genetics (ulcers may be hereditary)

A malignancy (tumor or cancerous mass)

Infections

Certain medications


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Percentage

81%

10%

7%

1%

1%1%

Causes

VenousArterial

Mixed

Diabetic

Malignancy

Rheumatoid

O Brien et al., 2000


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Philips et al, 1991

Venous ulcers


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Venous ulcer

History of venous diseaseDVTs

Recurrent Painless Signs of venous hypertension

Haemosiderin Lipodermatoclerosis Eczema Flares/spider nevi

Note : Normal ABIs Painless

Tierney, 2009


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Commonly noted in the"gaiter" region of the legs.

Larger but shallower Moist granulating base,

irregular border. This base oozes venous

blood when manipulated. The tissue surrounding these

ulcers may exhibit signs of

stasis dermatitis. mild pain that is relieved by

elevation.

Venous ulcers

Gabriel, 2012


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Arterial ulcers

Atherosclerosis

Skin crack

Arterial embolization

Inadequateperfusion

Ulcer

Ischemia

Necrotic tissue

Mekkes et al., 2003


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Arterial

History of intermittent claudication

Pain

Absent pulses

Reduced ABIs

Beware

Colour

Temperature

Capillary filling unreliable

Tierney, 2009


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Located distally and on the dorsum of the foot or

toes. Irregular edgesa better-defined appearance.

Grayish, unhealthy-appearing granulation tissue. Debridingbleed very little or not at all. Characteristic pain

Characteristic findings of chronic ischemia(hairlessness, pale skin, and absent pulses)

Gabriel, 2012


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Anders et al., 2010


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Wong, 2014


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Chadwick et al.,2013


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Pressure

Neuropathic


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Management

Debridement

Pressure control

Infection control

Exudate management

Mustoe et al., 2006


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TIME framework

issue debridement

Inflammation and infection control

Moisture balance (optimal dressing selection)

Epithelial edge advancement



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Debridement

Methods of debridement used including surgical/sharp, larval,autolytic and, more recently, hydrosurgery and ultrasonic

The requirement for further debridement should be determined ateach dressing change.

No one debridement method has been shown to be more effectivein achieving complete ulcer healing

Removes necrotic/sloughy tissue and callus

Reduces pressure, allows full inspection of the underlying tissues Helps drainage of secretions or pus

Helps optimise the effectiveness of topical preparations Stimulates healing



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Pressure control

The key to the successful healing of chronic venous ulcers will be tocorrect the underlying venous hypertension using graduatedcompression therapy

Education for patients regarding the need for life long support ofthe veins in their legs is paramount and should be emphasised fromthe beginning of treatment.

Several different types of bandaging systems are available, each of

which may have advantages over the others for particularapplications.

EWMA, 2003; Moffatt, 2007


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Infection control

Start empiric oral antibiotic therapy targeted at Staphylococcusaureus and -haemolytic Streptococcus

Change to an alternate antibiotic if the culture results indicate amore appropriate antibiotic

Obtain another optimum specimen for culture if the wound does

not respond to treatment.

Topical antimicrobials benefit in: Concerns regarding reduced antibiotic tissue penetration

poor vascular supply clinical suspicion of increased bacterial bioburden



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Common topical antimicrobial agents

Silverdressings containing silver (elemental, inorganiccompound or organic complex) or silver sulphadiazine cream/dressings

Polyhexamethylene biguanide (PHMB)solution, gel or

impregnated dressings Iodinepovidone iodine (impregnated dressing) or cadexomer

iodine (ointment, beads or impregnated dressings) Medical-grade honeygel, ointment or impregnated dressings

Topical antimicrobial agents should not be used alone in those withclinical signs of infection



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Exudate management

Dressings that can help to manage wound exudate optimally andpromote a balanced environment are key to improving outcomes

Consider :

Location of the wound Extent (size/depth) of the wound Amount and type of exudate The predominant tissue type on the wound surface Condition of the periwound skin Compatibility with other therapies (eg contact casts)

Wound bioburden and risk of infection Avoidance of pain and trauma at dressing changes Quality of life and patient wellbeing



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The best dressing

There is no consensus about the best agent. The method of debridement chosen may depend on the status of

the wound, the capability of the healthcare provider and theoverall condition of the patient.

It is common to combine methods of debridement in order to maximize the healing rates.

Barbul, 2007


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Adjunctive therapy

Considered when needed and available

Ulcers not healed with conventional therapy

Growth factor (PDGF, GCSF)

Negative pressure wound therapy Biological dressing

Bioenginered skin equivalent

Hyperbaric oxygen therapy Platelet rich plasma

Greer, 2012


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Conclusions Knowledge about etiology and pathophysiology of

the lower extremity ulcers is needed to managepatients with ulcer in lower extremity;

Vascular contribution plays major role in the ulcer of

the lower extremity;

Three important components of ulcer management: treat the causes, treat persons related complaints,

treat the wound


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Gist, 2009


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Stages of chronic venous

insufficiency(Expert meeting in Moscow, 2000.)

0 - no symptoms;

1 - heavy feet syndrome;

2 - intermittent edema;

3 - persistent edema, hyper- or

hypopigmentation, lipodermatosclerosis,eczema;

4 - venous ulcer.


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Documents

Lower Extremity Ulcer