Non-surgical and drug treatments

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Non-surgical treatments Bandages and hosiery Compression bandages are used to treat lower limb ulcers secondary to venous insufficiency (venous leg ulcers) and lymphoedema. Single layer compression bandages (elastic) are classified into four groups according to the predetermined levels of compression they provide at the ankle. Inelastic compression bandages (short stretch), when applied at full extension, improve the calf muscle pump action and exert higher pressures when the patient is upright (and walking) and lower pressures at rest. They are useful in patients who are adequately mobile. An elasticated tubular bandage (one to three layers) may be useful to treat and prevent venous leg ulcers. Non-surgical and drug treatments to consider in the treatment of chronic ulcers View this table: In this window In a new window Caution in use of compression bandages Multilayer compression bandaging, such as the four layer method, is well established in the management of venous leg ulcers. It consists of four layers—padding, a crepe bandage, and classes 3a and 3b (UK classification) compression bandages—applied from the base of the toes to knee. Ideally, it should be left in place for four to seven days. Although effective, the bulkiness of these layers may lead to non-compliance in some patients. Its use is limited in heavily exuding ulcers as repeated dressing changes may be needed. Top left: Single layer elastic compression bandage. Top right: Inelastic (short stretch) compression bandage. Left: Three layer elasticated tubular bandage This is the 11th in a series of 12 articles Graduated compression hosiery (UK classes I to III) is primarily used to prevent recurrence of venous leg ulcers and to control symptoms associated with varicose veins. The use of compression hosiery below the knee is associated with increased patient adherence Medicated bandages such as zinc paste bandages can be useful in treating some leg ulcers. They can be left undisturbed for up to a week. A zinc paste bandage containing calamine, coal tar, or ichthammol can be used if there is associated venous eczema. Medicated bandages provide no compression. Medicated bandage Intermittent pneumatic compression Intermittent pneumatic compression is effective in treating longstanding venous leg ulcers associated with severe oedema that are refractory to conventional compression therapy alone. Intermittent pneumatic compression device Intermittent pneumatic compression provides compression (range 20-120 mm Hg) at preset intervals (average 70 seconds) through an electrically inflatable “boot” of variable lengths. It is generally used two hours a day for up to six weeks. It improves venous and lymphatic flow and is useful in patients with comorbidities that limit mobility. It should be used as an adjunct to, rather than a substitute for, conventional compression therapy. Care should be taken in patients with cardiac failure. Diabetic foot ulcer suitable for vacuum assisted closure therapy (far left) and vacuum assisted closure in situ (left). Vacuum assisted closure Vacuum assisted closure is a non-invasive, negative pressure healing technique that is used to treat a wide range of chronic, non-healing wounds. Left: Grade 4 sacral pressure ulcer suitable for vacuum assisted closure therapy. Right: Vacuum assisted closure in situ The vacuum assisted closure device uses controlled subatmospheric pressure to remove excess wound fluid from the extravascular space, leading to improved local oxygenation and peripheral blood flow. This promotes angiogenesis and formation of granulation tissue, which are particularly useful in deep cavitating wounds to expedite “filling” of the wound space. Left: Pressure ulcer before debridement with larval (maggot) therapy. Right: The same ulcer 12 days after debridement with larval therapy (with maggots in situ) Vacuum assisted closure is contraindicated in patients with thin, easily bruised or abraded skin and in those with neoplasms as part of the wound floor. Cost and patient adherence may be issues of concern in some cases. Hyperbaric oxygen The use of hyperbaric oxygen has been recommended as an adjunctive therapy to treat a variety of non-healing wounds (as many non-healing tissues are hypoxic). Treatment is given by increasing the atmospheric pressure in a chamber while the patient is breathing 100% oxygen. Side effects such as seizures and pneumothorax have been reported with hyperbaric oxygen. A systematic review of the Cochrane database, however, has found insufficient evidence for its effectiveness in healing chronic wounds, although it might have a role in reducing the risk of major amputation in patients with diabetic foot ulcers (see third article this series). Biosurgery (myiasis) Biosurgery uses sterile maggots (usually of the green bottle fly, Lucilia sericata), which digest sloughy and necrotic material from wounds without damaging the surrounding healthy tissue. They have been shown in small scale trials to be useful in the treatment of venous, arterial, and pressure ulcers. Some patients complain of increased pain in the wound, and psychological discomfort and aesthetics may be issues for some individuals. Other approaches Other non-surgical approaches that have a scientific basis and thus have been advocated in the treatment of chronic wounds include radiant heat dressing, ultrasound therapy, laser treatment, hydrotherapy, electrotherapy, electromagnetic therapy, and PUVA therapy (psoralen plus ultraviolet A irradiation). However, few randomised controlled trials have studied the effectiveness of these treatments. Further rigorous randomised controlled trials are necessary to ascertain the type of ulcers that may benefit from treatment with hyperbaric oxygen Further reading Cullum N, Nelson EA, Fletcher AW, Sheldon TA . Compression for venous leg ulcers. Cochrane Database Syst Rev 2001; (2): CD000265. Berliner E, Ozbilgin B, Zarin DA . A...