Compression bandaging: Compression bandaging is the most important treatment for venous skin ulcers. This counteracts the raised pressure in the leg veins, which gives the best chance for the ulcer to heal. The common method is to put on three to four layers of bandages over the dressing, with the highest pressure at the ankle, and gradually decreasing towards the knee and thigh. A compression stocking over the dressing is sometimes used as an alternative, but not thought to be as good as bandaging. The bandages are re-applied every week or so when the ulcer dressing is changed. When using a compression bandage, the individual should still be able to move the ankle. It is important not to have the compression too tight or it may affect the circulation in the legs. Bandages should be removed immediately if the foot changes color or temperature or if there is increasing pain in the legs. A doctor should be consulted immediately if pain, temperature, or color of the area changes.
Elevation and activity:
When at rest, healthcare professionals recommend that individuals try to keep the leg elevated (raised) higher than the hip. This is particularly important if the leg is swollen. The aim is to let gravity help to pull fluid and blood in the right direction - towards the heart. This reduces swelling in the leg and reduces the pressure of blood in the leg veins.
It is also recommended to try to set three or four periods per day of about 30 minutes to lie down with the leg raised. It is important not to spend too much time in bed or resting. Keeping active and performing normal activities is important. If possible, regular walks are good, but do not stand for long periods.
When sleeping, it is important to try to keep the leg raised. Pillows under the bottom of the mattress can be used.
Smoking cessation: Smoking cessation is important to decrease the risk of developing a venous skin ulcer. The chemicals in cigarettes may interfere with the skin healing.
Antibiotics: Antibiotics are sometimes used for short periods if the skin and tissues around the ulcer become infected.
Pain management: Medications for pain may be prescribed if the ulcer is painful. Medications may include non-steroidal anti-inflammatory drugs, such as ibuprofen (Motrin®), or opiates, such as hydrocodone (Vicodin®, Lortab®).
Other treatments: Other treatments for venous skin ulcers include a healthy diet (such as increasing green, leafy vegetables and decreasing fatty foods) and surgery.
Most venous ulcers heal within 12 weeks if treated with compression bandaging. If compression is not used and an ordinary dressing or compression stockings alone are used, healing is inhibited.
Once a pressure ulcer is identified, steps must be taken immediately to: relieve the pressure on that area by using pillows, special foam cushions, and sheepskin; treat the sore based on the stage of the ulcer - a healthcare provider will give specific treatment and care instructions; avoid further trauma or friction by powdering the sheets lightly to decrease friction in bed; And improve nutrition and other underlying problems that may affect the healing proces. If the pressure ulcer is at Stage II or worse, a healthcare provider will give specific instructions on how to clean and care for open ulcers to prevent infection. Keeping the area clean and free of dead tissue is also important. A healthcare provider will give specific care directions. Generally, pressure ulcers are rinsed with a salt-water rinse to remove loose, dead tissue. The sore should be covered with special gauze dressing made for pressure ulcers. Do not massage the area of the ulcer, as massage may damage tissue under the skin. Donut-shaped or ring-shaped cushions are not recommended. They interfere with blood-flow to that area and cause complications, such as pressure sores.
Non-surgical treatment: Treating pressure sores is challenging. Open wounds are slow to close, and because skin and other tissues have already been damaged or destroyed, healing may be imperfect. Although it may take some time, most stage I and stage II sores will heal with conservative measures. But stage III and stage IV wounds, which are less likely to resolve on their own, may require surgery.
The first step in treating a sore at any stage is relieving the pressure that caused it. Pressure can be reduced by: changing positions often. Carefully follow a schedule for turning and repositioning - approximately every 15 minutes if in a wheelchair and at least once every two hours when in bed. If the individual is unable to change positions on their own, a family member or other caregiver may help. Using sheepskin or other padding over the wound can help prevent friction when moving.
Using support surfaces is important.
These are special cushions, pads, mattresses, and beds that relieve pressure on an existing sore and help protect vulnerable areas from further breakdown. The most effective support depends on many factors, including the individual's level of mobility, their body build, and the severity of their wound. Healthcare professionals recommend avoiding using pillows and rubber rings, which actually cause compression.
Sleeping mattress should be low-air-loss beds or air-fluidized beds. Low-air-loss beds use inflatable pillows for support, whereas air-fluidized beds suspend the individual on an air-permeable mattress that contains millions of silicon-coated beads. These beads help cushion areas of the body susceptible to pressure sores, such as the buttocks.
Other non-surgical treatments of pressure sores include cleaning the wound to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores should be cleaned with a saltwater (saline) solution each time the dressing is changed. Saline solution is available at a pharmacy or can be made at home by boiling 1 teaspoon of salt in 1 quart of water for five minutes. It is recommended by healthcare professionals to store the solution in a sterile container and cool before using. It is best to avoid antiseptics such as hydrogen peroxide and iodine, which can damage sensitive tissue and delay healing.
Controlling incontinence as far as possible is crucial to helping sores heal. If the individual is experiencing bladder or bowel problems, they may be helped by lifestyle changes, behavioral programs, incontinence pads, or medications.
To heal properly, wounds need to be free of tissue that is damaged, dead, or infected. One approach to removing dead tissue is surgical debridement, a procedure that involves using a scalpel or other instrument to remove dead tissue. Surgical debridement is quick and effective, but it can be painful. A doctor may use one or more non-surgical approaches. These include removing devitalized tissue with a high-pressure irrigation device (mechanical debridement), allowing the body's own enzymes to break down dead tissue (autolytic debridement), or applying topical debriding enzymes, such as Granulex®.
Dressings: A variety of dressings are used to help protect wounds and speed healing. The type of dressing used usually depends on the stage and severity of the wound. The basic approach, however, is to keep the wound moist and to keep the skin surrounding the wound dry. Stage I sores may not need any covering, but stage II lesions are usually treated with hydrocolloids or transparent semi-permeable dressings that retain moisture and encourage skin cell growth. Examples of hydrocolloid dressings include Tegasorb® and Relicare®. Other types of dressings may be more beneficial for weeping wounds or those with surface debris. Contaminated sores may also be treated with a topical antibiotic cream.
Hydrotherapy: Whirlpool baths can aid healing by keeping skin clean and naturally removing dead or contaminated tissue. Whirlpool baths used for burn treatment are specialized, stainless steel baths used by trained healthcare professionals.
Healthful diet: Eating a nutritionally rich diet with adequate calories and protein and a full range of vitamins and minerals, especially vitamin A, vitamin C, Vitamin E, iron, and zinc, has been reported to improve wound healing. A well nourished body can produce healthful skin, which guards against breakdown.
Surgical repair: The goals of surgical repair include improving the appearance of the sore, preventing or treating infection, reducing fluid loss through the wound, and lowering the risk of future cancer. The type of reconstruction that's best in any particular case depends mainly on the location of the wound and whether there's scar tissue from a previous operation. In general, though, most pressure wounds are repaired using a pad of muscle, skin, or other tissue that covers the wound and cushions the affected bone (flap reconstruction). The tissue is usually harvested from the individual's own body. In spite of every precaution, flap reconstruction has one of the highest complication rates of any surgery, and the recovery period is long and arduous. Individuals must have a strong social support system, optimal nutritional status, state-of-the-art resources such as a pressure-release bed, and the ability and motivation to participate in their own recovery to be a candidate for this operation.
Other treatment options: New treatment options for wound healing include hyperbaric oxygen, electrotherapy, and the topical use of human growth factors. Growth factors, proteins that stimulate cell growth, have been approved for the treatment of diabetic ulcers but have not been approved for pressure sores to date.
Unclear or conflicting scientific evidence
Aloe: Transparent gel from the pulp of the meaty leaves of Aloe vera has been used topically for thousands of years to treat wounds, skin infections, burns, and numerous other dermatologic conditions. Study results of aloe on wound healing are mixed with some studies reporting positive results and others showing no benefit or potential worsening of the condition. Further study is needed.
Arginine: Arginine, or L-arginine, is considered a semi-essential amino acid, because although it is normally synthesized in sufficient amounts by the body. Arginine has been suggested to improve the rate of wound healing in elderly individuals. A randomized, controlled clinical trial reported improved wound healing after surgery in head and neck cancer patients, following the use of an enteral diet supplemented with arginine and fiber. Arginine has also been used topically (on the skin) to attempt to improve wound healing. Further research is necessary in this area before a firm conclusion can be drawn.
Aromatherapy: Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary data from one small study suggest that aromatherapy may contribute to reduced pain intensity during dressing changes in wound care. Data are insufficient for forming any opinion for or against this application.
Calendula: Calendula (Calendula officinalis), also known as pot marigold, has been widely used on the skin to treat minor wounds, skin infections, burns, bee stings, sunburn, warts, and cancer. Calendula is commonly used topically (on the skin) to treat minor skin wounds. Reliable human research is necessary before a firm conclusion can be drawn.
Chamomile: Chamomile (Matricaria recutita, Chamaemelum nobile) has been used medicinally for thousands of years and is widely used in Europe. There is promising preliminary evidence supporting the topical use of chamomile for wound healing. However, the available literature is not adequate to support the use of chamomile for wound healing.
Dimethylsulfoxide (DMSO): Dimethylsulfoxide (DMSO) is a sulfur-containing organic compound. DMSO occurs naturally in vegetables, fruits, grains, and animal products. DMSO applied to the skin may prevent tissue death after extravasation of anticancer agents. It can be applied alone or with steroids. Further research is needed to confirm these results. Currently, there is not enough scientific evidence available for the use of topical DMSO for diabetic ulcers. One trial suggests that DSMO improves the lack of blood flow (ischemia) in surgical flaps. More research is needed to confirm these results.
Gotu kola: Gotu kola is from the perennial creeping plant, Centella asiatica (formerly known as Hydrocotyle asiatica), which is a member of the parsley family. Gotu kola has a long history of use, dating back to ancient Chinese and Ayurvedic medicine. Preliminary study has demonstrated the ability of Centella asiatica extracts to promote wound healing, possibly through the stimulation of collagen synthesis. However, additional human study is needed in this area.
Honey: Honey is a sweet, viscid fluid produced by honeybees (Apis melliflera) from the nectar of flowers. The primary studied use of honey is for wound management, particularly in promoting rapid wound healing, deodorizing, and debriding necrotic tissue. The types of wounds studied are varied; most are non-healing wounds such as chronic ulcers, postoperative wounds, and burns. Although honey has apparent antibacterial effects, more human study is needed in this area.
Honey dressings have been used on leg ulcers with no apparent clinical benefit. Currently, there is insufficient human evidence to use honey for the treatment of split-thickness skin graft. Additional study is needed.
Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. These approaches have been used for the relief of various diseases and injuriesand for general well-being. Hydrotherapy has been used in patients with pressure ulcers and preliminary research suggests that daily whirlpool baths may reduce the time for wound healing. Better research is necessary in this area before a firm conclusion can be drawn. There is a risk of infection from contaminated water if sanitary conditions are not maintained.
Iodine: It is not clear if healing of wounds or skin ulcers is improved with the application of topical iodine solutions. Iodine solutions may assist with sterilization as a part of a larger approach to the healing process.
Pantothenic acid (vitamin B5): Pantothenic acid (vitamin B5) is a component of coenzyme A (CoA), a molecule that is necessary for numerous vital chemical reactions to occur in cells. Pantothenic acid is essential to the metabolism of carbohydrates, proteins, and fats, as well as for the synthesis of hormones and cholesterol. In animal research, oral and topical pantothenic acid has been associated with accelerated skin wound healing. However, early human study results conflict. Additional evidence is necessary before a clear conclusion can be reached regarding this use of pantothenic acid or dexpanthenol.
Physical therapy: Physical therapy techniques, such as laser treatment, have been used to clean and heal wounds. Early evidence also suggests that high voltage stimulation or pulsed electrical stimulation may speed the healing of some types of skin ulcers. More research with similar outcomes measures is needed to confirm these findings. Individuals with leg ulcers may need special care during physical therapy due to compromised skin integrity. A healthcare professional will determine what is best for each individual.
Psyllium: Psyllium, also referred to as ispaghula, is derived from the husks of the seeds of Plantago ovata. Psyllium contains a high level of soluble dietary fiber and is the chief ingredient in many commonly used bulk laxatives. Results from one human study suggest psyllium reduced the number of surgeries necessary to heal anal fissures. Further evidence is necessary.
TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. TENS is often used to treat pain, as an alternative or addition to pain medications. Therapy sessions may last from minutes to hours. TENS is often used in conjunction with acupuncture therapy. TENS has been tested for its effects on blood flow to skin flaps used in plastic surgery procedures such as breast reconstruction. TENS has also been evaluated in patients with diabetic foot ulcers and chronic ulcers of other causes. There is not enough reliable evidence to draw a firm conclusion in this area.
Therapeutic touch: Although some studies report an improvement in wound healing with therapeutic touch, others show no benefits.
Vitamin A: In preliminary study, retinol palmitate significantly reduced rectal symptoms of radiation proctopathy, perhaps because of wound-healing effects. Further research is needed to confirm these results.
Zinc: Although zinc is frequently cited as having beneficial effects on incision wound healing, few studies have investigated this use. Further research is needed. There are conflicting findings regarding the potential benefit of zinc for healing leg ulcers. All studies, however, reported no or few adverse effects.
Preliminary evidence suggests that topical zinc oxide oil may help manage perianal and buttock skin damage in incontinent patients. Further research is needed to confirm these results.
Traditional or theoretical uses lacking sufficient evidence
Integrative therapies used in leg/skin ulcers that have historical or theoretical uses but lack sufficient clinical evidence include: abuta (Cissampelos pareira), acupuncture, alizarin, arnica (Arnica montana), avocado (Persea americana), bee pollen, beta-glucan, blessed thistle (Cnicus benedictus), boswellia (Boswellia serrata), bovine cartilage, devil's claw (Harpagophytum procumbens), echinacea (E. angustifolia, E. pallida, E. purpurea), topical eucalyptus oil (E. globulus), ginseng (Panax ginseng), goldenseal (Hydrastis canadensis), guggul (Commifora mukul), guided imagery, lavender (Lavandula angustifolia), magnet therapy, noni (Morinda citrifolia), nopal (Opuntia sp.), ozone therapy, Pycnogenol® (Pinus pinaster ssp. atlantica), reiki, resveratrol, rosemary (Rosmarinus officinalis), sea buckthorn (Hippophae rhamnoides), shark cartilage, tamanu (Calophyllum inophyllum), tea tree oil (Melaleuca alternifolia), and urine therapy.
Venous leg ulcers commonly recur after they have healed. To prevent this, individuals should wear support (compression) stockings during the daytime for at least five years after the ulcer has healed. This counteracts the raised pressure in the veins that causes venous leg ulcers. A new stocking should be purchased about every six months, as the elastic tends to degrade.
There are different classes (strengths) of compression stockings - class I, II, and III. The higher the class (class three), the greater the compression. Ideally, healthcare professionals recommend that patients with venous leg ulcers wear class three stockings. However, some people find class three stockings too tight and uncomfortable. In such cases, class two may be fine; it is still best to wear some sort of compression stocking than none at all.
Underlying conditions, such as diabetes, should be controlled. A healthcare provider will work with the individual to help control daily blood sugar levels.
If bedridden or immobile with diabetes, circulation problems, incontinence, or mental disabilities, healthcare providers recommend that the individual be checked for pressure sores every day. Also, look for reddened areas that, when pressed, do not turn white. It is important to look for blisters, sores, or craters. In addition, take the following steps: change position at least every two hours to relieve pressure; use items that can help reduce pressure (such as pillows, sheepskin, foam padding, and powders from medical supply stores); eat healthy, well-balanced meals; exercise daily, including range-of-motion exercises for immobile patients; and keep the skin clean and dry. Incontinent people need to take extra steps to limit moisture in the genital area.
Individuals with diabetes should check their feet daily for blisters, sores, or other wounds in order to prevent serious infection and possibly amputations.