Therapy of (venous) ulcers Don’t just put up with an ulcerated leg
The Vein Center at the Ruhr University Departments of Dermatology and Vascular Surgery at St. Maria-Hilf Hospital in Bochum is an important treatment facility for patients suffering from venous ulcers. Prof. Markus Stücker, President of the German Society of Phlebology and Dermatology and director of the center, describes the different types of ulcerations that can afflict the legs and the methods used to treat them.
Your facility was certified as a vein treatment center in 2015. What are the particular strengths of your clinic?
Prof. Stücker: The interdisciplinary cooperation between dermatologists and vascular surgeons enables us to provide highly specialized care for our patients. We perform more than 2,000 major varicose vein operations each year and treat between 50 and 60 patients with venous ulcers every month, whereby 300 patients a year are inpatients who need to stay in the clinic because of infections or wounds that are difficult to treat. It’s important to us to avoid invasive procedures as much as possible while still providing effective long-term treatment.
How long have most of your patients had an ulcer before they come to you?
Prof. Stücker: In the past , we had many patients who had been suffering from a venous ulcer for several years before seeking treatment. These days, people come to us much more quickly, usually after four to five weeks.
The advantage of early diagnosis is that the ulcer is smaller and mobility is not yet all that restricted, which means cause-related therapy can begin earlier. In addition, more and more people are now aware of the fact that the sooner treatment begins, the less drawn-out and painful it will be – and that it might even be possible to avoid surgery in such cases. Moreover, family physicians are now more knowledgeable about the condition and send their patients to specialists at an earlier stage. Our vein center has excellent working relationships with many family physicians.
What types of ulcers can occur, and how are they treated?
Prof. Stücker: A venous ulcer, which is a wound on the lower leg that has trouble healing, can have many different causes, so the treatment methods vary as well. The top priorities – along with the treatment of the underlying condition – are to quickly eliminate what in many cases is severe pain, implement a defect closure, and prevent infection.
The most common cause of a venous ulcer is chronic venous insufficiency (CVI), which in turn can be triggered by varicose veins or post-thrombotic syndrome. Ulcerations can also form as a result of a narrowing of the arteries, vasculitis, peripheral artery disease (PAD), a malignant condition such as squamous cell carcinoma, or nerve damage (polyneuropathy). In each case, we perform a standardized diagnosis, as well as a duplex ultrasound and a vein function test , among other things. We also conduct an ankle-brachial pressure index test and check the sensitivity of the feet. This gives us a good overview of where the patient’s veins are damaged and to what extent. After that , we begin causal treatment. In around half of the cases we deal with, this means treating existing varicose veins. Compression therapy then forms the basis for all subsequent treatment options.
How does compression support the healing process?
Prof. Stücker: The decelerated blood flow caused by CVI results in white blood cells continually collecting on the vein walls, which leads to inflammation. Compression reduces the diameter of the vein walls, which in turn increases the blood flow rate and thus reduces the number of white blood cells that can collect on the walls. The risk of inflammation then decreases as a result.
At what point during the treatment can a compression stocking be used?
Prof. Stücker: Compression therapy is carried out in two stages. In the first stage – the decongestion phase – a compression bandage is used. To begin with, this bandage is changed daily: Later on it’s changed every two to four days. Our patients benefit here from our good cooperation with physicians in private practice, as well as with outpatient services. The latter employ specially trained wound nurses and wound care assistants who provide us with information on the characteristics of the wound by sending us images, for example. They also consult with us regarding further treatment options. After the decongestion phase, we begin using an ulcer stocking system until the ulceration has healed. If the ulcer was caused by a disorder of the deeper guide veins, the patient will have to continue to consistently use medical compression stockings in order to prevent a relapse.
What experiences have you had with using the VenoTrain ulcertec for treating ulcers?
Prof. Stücker: We prefer to use the VenoTrain ulcertec stocking system in most cases, as we believe it offers several advantages over supports. For example, it’s relatively easy for both carers and patients to put on, and the predefined pressure is continually maintained. Patients enjoy greater freedom of movement in the ankle with it. They can also wear normal shoes and they remain more mobile in general. All you need to wear overnight is a liner, so the wound remains properly bandaged and the compression can be reduced.
Can the VenoTrain ulcertec be used to treat all ulcerations?
Prof. Stücker: Yes, there are no restrictions here, even in the case of very large ulcers. It can even be used to effectively treat mixed arterial and venous ulcers – simultaneous CVI and PAD – provided the ankle pressure is no lower than 60 mm Hg. Most of the ulcers heal within two to three months, and signs of healing become apparent much sooner than that. In general , medical compression stockings have become well-established tools for treating ulcers, and care staff also find them easy to use.
How high is the recurrence rate for ulcer conditions?
Prof. Stücker: The recurrence rates are getting lower because causal treatments are being used and damaged veins are being shut down more and more often. After an ulcer heals, our focus turns to further treatment of the venous insufficiency. Patients these days are also better at using their stockings consistently. In addition, they understand that venous ulcers are not some great irreversible misfortune that has befallen them, but instead something that can be treated and healed. They also understand how the treatment works.
Pictures: Stefan Durstewitz, Prof. Dr. Stücker