Identifying and treating the causes

In many cases, venous leg ulcers can be cured if the right diagnosis is made and appropriate treatment is provided. Often, however, patients suffer for too long. Dr. Alfred Obermayer, Director of the Karl Landsteiner Institute for Functional Phlebosurgery, and Attending Physician at St. Josef’s Hospital in Vienna, is a Phlebologist, Specialist in Ulcer Surgery and Organizer for Wachau Vein Symposium. Sonja Koller, MBA, is the Head of the Wound Treatment Ward at Landesklinikum Melk hospital, a qualified and registered public health nurse as well as President of the Austrian Society for Wound Treatment. In their joint interview, they talk about diagnostics, treatment options and the use of VenoTrain ulcertec to combat venous leg ulcers.

life: Dr. Obermayer, you often see patients who have been suffering for a long time. Why does this keep happening?

Dr. Obermayer: Many practitioners only see the open wound on the leg as the problem, but we must ask ourselves: why does this patient have this wound in this place? From an endogenous perspective, the root cause is very often an insufficient vein that leads to an accumulation of blood low in oxygen within the skin. When you examine the area, the affected skin is red, itching and flaky. As a consequence of chronic bruising, iron deposits lead to hyperpigmentation. This means that even minor wounds do not heal well. In addition, we look for exogenous causes that may worsen the symptoms: many creams and types of wound dressing result in iatrogenic contact sensitization. This local treatment, though meant well, is introduced right into the tissue and can lead to stagnating healing or a progression of the ulceration. As we know, our immune system defends the body from external substances.

What other endogenous causes need to be considered?

Dr. Obermayer: The situation is plain and simple: In healthy veins, the hydrostatic pressure caused by gravity does not affect the skin’s microcirculation. If venous valves are defective, this pressure can compromise the skin’s microcirculation. Gravity is the problem – in zero gravity, nobody can get venous leg ulcers. On earth, however, each drop of liquid gravitates downward. Now, if the veins are insufficient, the pressure within the capillaries increases. Proteins and inflammatory cells get into the tissue, resulting in edema and inflammation. As a consequence, the skin is no longer supplied with sufficient nutrients. This is how ulcers develop. In the majority of cases I see, the patient’s hemodynamic situation has never been properly evaluated.

What method of examination is best?

Dr. Obermayer: We use ultrasonography to check where the pressure comes from. We refer to this search for the source as “sourcing”. Once you’ve identified the reflux path along which the pressure is exerted and the depleted deoxygenated blood presses against the skin from the inside, you can eliminate this supplying vein, using ultrasound-guided foam sclerotherapy, for example. When this vessel is obliterated, normal conditions return and wound healing can begin.

Does this mean that many years of futile treatment can be brought to a positive outcome after all?

Dr. Obermayer: Of course, there’s no reason why people need to suffer from venous leg ulcers for ten years. But another very important factor needs to be considered: compression therapy. If a leg affected by an ulcer is compressed effectively, swelling will subside, exudation will decrease, the ulcer will become dry and healing can start.

Koller: However, this is where we often find inadequate approaches to treatment. When we ask patients about previous diagnostics, we learn that nothing much has been done. Many treating physicians fully focus on the ulcer. They all have their own opinion as to which dressing should be used. And this is where lengthy suffering often starts, which can also affect mental health and can even lead to social isolation. When these patients then come to us, they have often lost their confidence in those treating them. Patients with chronic wounds aren’t necessarily physicians’ favorite clients. Wound management is very complex and costly, and there’s often a lack of this kind of time and resources in medical practices and nursing care organizations. That’s why those affected are often referred to other practitioners. But when trust has been established, a lot of lost ground can be regained. Even compression therapy, which patients would reject vehemently at first, is then accepted without problems.

Dr. Obermayer: It’s important that the treatment doesn’t make the condition worse. A lot of wound dressings tend to be applied, including occlusive dressings. But what happens? By excluding oxygen, you encourage the growth of anaerobic germs, and the wound will start to smell. We let air get to the wound to eliminate anaerobes. A crust indicates the conversion of the non-healing ulceration. We consider it to be the best occlusive dressing.

When do you use compression products for treatment?

Koller: Various factors need to be considered. It’s important to start decongestion with bandaging and compression wraps, and then use compression stockings after that. If they’re measured for a leg that still shows a high degree of swelling, it won’t fit later and will therefore not be effective. But that’s what a lot of treating physicians do – they prescribe compression stockings for a leg that hasn’t been decongested. But even the best stockings can’t be effective in this case. They may reduce swelling initially, but after that, they fit loosely. That’s when we need to ask the next questions: can the patient even put on the stockings? Does the patient have arthritic hands and needs help donning? Or: does the patient put on the stockings at the right time of day, i.e. in the morning? Or as late as noon when the leg has swollen again? And as a general rule, you need to check carefully whether the prescribed stockings are appropriate. We often see that size, length or circumference are simply wrong.

Is there the right stocking for every leg?

Koller: I would put it differently: a standard-size stocking doesn’t suit every leg. Sometimes, legs have developed shapes that require custom-made stockings. But apart from these very serious cases, a high-quality compression stocking provided during follow-up care ensures and improves patients’ quality of life. We gradually get our patients accustomed to them: Initially, we give them two liners – wearing two on top of each other during the day corresponds to compression class 2. At night, they only wear one. Once patients have got used to this, we switch them to the full compression stocking system, meaning compression class 3.

Dr. Obermayer: In my opinion, the VenoTrain ulcertec is a great choice, an excellent premium-quality product, because the combination of a lightweight liner and the firmer overstocking is perfect during the day. Compression therapy is crucial from a medical perspective, and that is why it’s impossible to overemphasize the significance of having compression products that patients actually want to wear because they offer a good degree of wearing comfort.

Ms Koller, your master’s thesis dealt with undesirable effects of compression: Which side effects can be expected?

Koller: They can include pressure-related problems and constriction. That’s why a compression stocking has to be prescribed and measured with great care. Otherwise, patients may get problems in the area of the Achilles tendon or the tibialis anterior tendon. The diagnosis must also consider whether there is a venous leg ulcer or a mixed leg ulcer with impaired arterial blood flow. And cases of neuropathy require particular care: this condition starts with damaging the fibers that transmit pain, meaning the patient doesn’t even notice the pressure or constriction.

How much participation do you expect from your patients?

Dr. Obermayer: At the Karl Landsteiner Institute for Functional Phlebosurgery, we’ve developed exercises to be carried out while the patient is lying down. We call them “active bed rest”. We use them with great success in addition to conservative, but especially surgical ulcer treatment. Patients wear their compression stockings and do their exercises whilst lying down: cycling, leg circles, combined with breathing exercises and training for the upper body. You wouldn’t even recognize the leg after two days! Patients must then continue with compression therapy as well as with these exercises. But modifying everyday habits is also important. For example, when they want to have a little rest in the afternoon, they should elevate their legs rather than sitting at a table. This way, fluid can be returned to the circulatory system. These seemingly minor details are crucial.

How long-term is the healing success?

Dr. Obermayer: Very good, very permanent. The majority of our patients have a simple epifascial insufficiency. Once the source of the problem is eliminated, they’re fine. But we do provide extensive patient education: they need to understand that this is their problematic leg. If it gets flaky, turns red, feels warm or you see an injury, etc., then please come and see us. Quite often, we can nip the problem in the bud. It’s trickier with patients suffering from post-thrombotic syndrome: but effective compression therapy gives them a good chance as well that the ulcer will remain closed up. However, they have to be particularly careful because completely different rules apply to this leg!

VenoTrain ulcertec A stockings is the best dressing

VenoTrain ulcertec supports wound healing. It consists of an overstocking and a liner. The liner is worn during the day and at night to hold the wound dressing in place, and its low resting pressure provides basic compression. During the day, the patient also wears the overstocking. Both components together ensure compliance with the contact pressure in the ankle area specified by the physician. Ankle mobility is compromised only to a minor extent.The overstocking is made of a rhomboid knitted fabric specially developed by Bauerfeind. Its structure, comparable to a lattice, exerts a high level of working pressure during movement. In order to meet different therapy needs, the VenoTrain ulcertec is available in two versions with different levels of ankle pressure (resting pressure): VenoTrain ulcertec 39 and VenoTrain ulcertec 46. If the edema has moved to the thighs, the VenoTrain ulcertec AG design is available (offering a thigh-high liner). Crucial for patients’ comfort is the liner’s skin-friendly material that can be washed at up to 95 °C and the overstocking’s knitted fabric which makes it easy to put on and take off. This reduces sweating, itching and constriction. Thanks to its relatively thin material, the VenoTrain ulcertec can be worn in ordinary shoes. Each set contains two liners.

Images: Bauerfeind, Dr. Alfred Obermayer