“Skin changes on the lower leg must be taken seriously”

Professor Dr. Michael Jünger, Director of the Clinic and Polyclinic for Skin Diseases at Greifswald University Hospital, explains how venous leg ulcers (CEAP classification C4–C6)¹ develop from varicose veins and what effective methods can be used to combat this process.

life: Professor Jünger, what would you consider to be a typical, severe case in phlebological practice?

Professor Dr. Michael Jünger: That would be venous leg ulcers. These are wounds that occur spontaneously or after minor trauma, usually on the lower leg in the region of the medial or lateral malleolus. In most cases, there are already pathological changes present in the skin at this point, i.e. there are signs of inflammation such as redness, hardening, eczematous abnormalities or itching.

Who is most commonly affected?

Professor Dr. Michael Jünger: On the one hand, there are people who have already suffered leg vein thrombosis. Another large group is patients with a genetic predisposi­tion to develop varicose veins. This affects not only the outer, visible veins, but also the deep veins. Then, there are more rare causes such as congenital malformations of the vessels called angiodysplasia.
The risk of developing an ulcer is further increased by other skin disorders, such as erysipelas, an autoimmune connective tissue disease called “collagenosis”, as well as concomitant conditions, including obesity or atherosclerosis associated with impaired arterial blood flow in the legs. For many of these conditions, class 1 compression stockings can provide relief following acute care.

What should physicians look out for?

Professor Dr. Michael Jünger: Clinical signs such as spider veins and lateral branch varicoses are initially harmless. However, leg edema or swelling in the lower leg is an indication of early chronic venous insufficiency. If the skin begins to show brownish discoloration and become hardened or starts itching, these are also considered clear signs. At this point, the physician should emphasize to the patient that the changes are caused by the varicose veins and that the venous congestion must be prevented by taking appropriate action. After all, many patients do not consider these changes to be problematic and disregard them for decades. In addition, there is one thing that should be borne in mind: once a venous leg ulcer has developed, the skin inflammation usually spreads to the joint capsule and causes the patient to adopt a relief posture to avoid the pain, resulting in limited mobility of the ankle joint. But moving the ankle joint is a prerequisite for muscle activity in the lower leg. The stiffening of the ankle joint means the most important motor for venous blood return from the leg to the heart is no longer active, leading to permanent venous congestion in the feet and lower legs also when walking, sitting and standing. An ulcer won’t heal as long as the venous congestion persists. The impaired activity of the calf muscle/ankle pump increases the risk of recurring ulcerations, and with it the likelihood of impaired lymphatic drainage because lymphatic capillaries in the skin are destroyed due to the ulcer.

What treatment options do you recommend?

Professor Dr. Michael Jünger: It’s not enough to apply ointments to the ulcer or the surrounding skin because venous congestion, i.e. the reason why the ulcer developed in the first place, still persists. Taking the clinical situation into account, it makes sense to use topical treatments in the form of tolerable ointments that are applied onto the ulceration and the surrounding tissue, but it does not combat the root cause: venous congestion. All measures to reduce venous congestion serve to initiate and facilitate wound healing. Compressive bandaging or an ulcer-specific compression stocking immediately improves or normalizes venous blood flow toward the heart. Physical therapy and vascular exercise help restore normal gait patterns and optimize the venous muscle pump of the calf and ankle.

Can compression therapy help prevent chronic venous insufficiency (CVI) and recurrence?

Professor Dr. Michael Jünger: If I reliably stop venous reflux by always wearing appropriate compression stockings when my legs are in a vertical position and by exercising, I can stop CVI from deteriorating. I have been providing support and advice to vascular exercise groups in conjunction with compression therapy for over ten years. Participants never, literally never, suffered recurrence, even though they had had a venous leg ulcer. However, they must always wear the compression while walking, sitting, standing or exercising. It is not necessary when you are in the water, because the water pressure on the leg corresponds to the contact pressure of the compression stockings and replaces it.

What other treatment options are available beyond compression?

Professor Dr. Michael Jünger: Other options include surgery on the superficial veins whose valves are not able to close properly, which means they no longer transport the venous blood to the heart: removal of the veins, called “stripping”, or eliminating these harmful veins using a catheter-based procedure (laser, radiofrequency, hot steam, acrylate glue) or by means of sclerotherapy, where a drug is injected that closes the vein. Removing problematic veins relieves the healthy ones because the reflux is stopped. If this is done early enough and the deep veins are still in good condition, the patient may be able to avoid compression. Or it may be sufficient for them to wear below-knee stockings with a light compression class. They are easier to handle for elderly patients. After all, compliance is a big issue.

What is the role of compression therapy in the treatment of wounds in cases of venous leg ulcers?

Professor Dr. Michael Jünger: First of all, the venous reflux, which is the root cause that led to the ulcer, must be eliminated. For this purpose, the use of a phlebological compression bandage or a compression stocking system is considered to prevent venous reflux toward the ulcer by applying pressure on the “outer” veins, i.e. the mall veins in the skin. This creates the basic conditions for local wound treatment to be effective. In the first phase of wound healing, the body removes the dead skin tissue. This stage can be accelerated by surgically removing the superficial slough with a scalpel. Then, the body starts to form new tissue (“granulation tissue”), which supports and nourishes the newly developing external skin layer. This stage can also be accelerated by applying skin grafts. In recent years, practitioners have also been applying stem cells to support skin formation in particularly hard-to-treat cases. Compression treatment is absolutely necessary for wound healing, also after skin transplants, to ensure in-growth and healing of the graft. In clinical practice, phlebological compression bandages are typically used. After that, a compression stocking system such as the VenoTrain ulcertec could take over this task.

What are the advantages of VenoTrain ulcertec compared to a phlebological compression bandage?

Professor Dr. Michael Jünger: VenoTrain ulcertec is less thick and more comfortable to wear. What is more, good bandaging always depends on the person who applies it. A special compression stocking in connection with wound care, on the other hand, constantly exerts the necessary contact pressure.

What specific problems do older patients face?

Professor Dr. Michael Jünger: At an advanced age, some patients suffer from dangerous comorbidities that can play a role in therapy. Some take anticoagulants, for example. This must be taken into account when considering conventional surgery. Here, I recommend minimally invasive procedures or the continuation of compression therapy. Another issue are changes on the feet, which affect everyone as we get older. Last but not least, elderly patients have less strength in their hands or suffer from soft tissue rheumatism, which makes it more difficult for them to apply compression stockings. Here, too, the VenoTrain ulcertec can help. This is because the liner is easier to put on, for example, even over a wound dressing. It can then serve as a donning aid for the firmer overstocking.

Is there anything else to consider?

Professor Dr. Michael Jünger: It is important to consider co-morbidities when applying compression at any age. In patients with severe heart failure, for example, I try targeting the heart instead of prescribing compression therapy. Or take diabetes mellitus, especially in connection with polyneuropathy: if patients don’t feel when the stocking doesn’t fit properly or produces folds, this can create a non-healing wound. A poor diet can also be problematic: for example, the compression stocking won’t fit securely on an extremely obese leg, which will impair its effectiveness, while in malnourished patients, pressure on bony protrusions can cause skin damage. In these cases, it’s preferable to use compression class 1.

What would you like to recommend to doctors and patients?

Professor Dr. Michael Jünger: Always keep an eye on the legs and take skin changes seriously. Doctors should be alert when someone requests water pills for swollen feet or lower legs. Manual lymphatic drainage, which helps to decongest the feet and lower legs, should always be combined with compression therapy (bandage, stockings). I’m confident that, if the patient and their expert healthcare professionals form a team that communicates with each other, they will be successful in achieving the goal of healthy legs.

A skillful duo for wound and vein treatment

The VenoTrain ulcertec compression stocking system consists of a liner and an overstocking and offers a dual strategy for wound and vein treatment, particularly during the healing phase of a venous leg ulcer. It is available in two designs for mild or firm compression.

The liner secures the wound dressing by applying continuous gentle compression without slipping. This promotes healing 24/7, even during sleep. It is available as a below-knee or thigh-high model.

The overstocking is worn over the liner, which – in combination with the unique rhomboid knit – makes it easier to put on and take off the stocking. Because of the lattice-shaped knitted fabric, this ulcer-specific compression stocking offers compelling effectiveness: venous reflux is reliably prevented, and venous return from the lower leg toward the heart is improved or normalized. Because VenoTrain ulcertec is thinner than conventional bandages, it fits inconspicuously in any shoe without slipping.

More information at:
www.bauerfeind-­group.com/ulcertec

1 Lurie F. et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord, 2020;8(3):342-52.

Images: Bauerfeind, Steffi Behrmann, Anika Büssemeier, AdobeStock/Catalina/tpap8228/tibanna79