Topical Management of arterial and venous ulcers - VascularWeb

Professor of Surgery Chief, Division of Vascular SurgeryUniversity of North CarolinaTopical Management of arterialand venous ulcers

Arterial and venous ulcers:Differences in their topicalmanagementBill MarstonProfessor and Chief,Division of VascularSurgeryUNC Hospitals

DisclosuresScientific Consultant• Organogenesis• Spiracur• Aastrom BiosciencesResearch support• Healthpoint

What do I put on the wound?• Wound gel• Hydrogel• Duoderm• Cutinova• Silvadene• Bactroban• Triple antibiotic• Santyl• Integra, primatrix,graftjacket, dermagraft,apligraf• Acticoat• Alginate• Aquacel• Iodoform• Solosyte• Sorbsan• Curusol• healusol

Venous/lymphatic ulcer• Common assoc withobesity• Typically requirestreatment of bothetiologies• Heavily exudative• Biofilm issues

Arterial ulcer• Most assoc w DM• Pressure sites• Neuropathy• Tissue necrosis

• May be inatypicallocations• Typically dryunless infected• Gangrenouschanges

Combined arterial and venous• Occurs in approx20% of cases ofleg ulceration• Critical to evaluateeach ulcer formultiple causes• Compressionrelated necrosisinsufficiency

Causes of Atypical WoundsInfectiousMalignancyGeneticHematologicAtypical WoundsMetabolicImmunologicInflammatoryPsychologic

Other ulcer etiologies• Vasculitis• Vasculopathy• Pyodermagangrenosum• Malignancy• Sickle Cell• Etc, etc

When to biopsy a• Long durationchronic wound• Poor response togood therapy• Looks funny• Send tissue forpath & cx

Common final pathway in chronicwounds: Unregulated inflammation• Sources– venous hypertension– Chronic pressure– Bacterial overgrowthTreatment methods– Compression0.020.0180.0160.0140.0120.010.0080.0060.0040.002– Contact cast 0TNF-a in venous ulcerNormalBefore

Rx protocol for VLU• Compression• Wound debridement/elimination ofbacteria• Exudate control• Adjuvant therapies to accelerate closure• Prevention of recurrence

What type of compression andhow much?• High strength elastic compression stockings• Short stretch bandage• Long stretch bandage• Unna’s paste boot• Multilayered compressive wrap– Elastic– Inelastic• Intermittent pneumatic compressionCompression must be part of any RX plan for VLU

Coexistent arterial insufficiency:How much compression?• Incidence of coexistent arterialinsufficiency– Diabetic foot ulcer 50-60%– Venous ulcer 15-20%• If ABI < 0.8 or toe pressure < 70,consider reduced compression• If ABI

Pressure Offloading: TotalContact Casting• Katz et all, randomized trial of TCC forplantar DFUs• 12 week healing rate• BUT– 93% for those who stayed in TCC at least 8weeks– 80% for all randomized to TCC– Diabetes Care 2005;28:55-9• Only 1.7% of clinics treating patients withDFUs reported using TCCs to offloadpatients– Wu et al Diab Care 2008;31:2118

Topical therapy• Wound debridement• Control of woundbacterial levels• Management ofwound drainage• Dressing selection

Why debride?• Presence of non-viable/necrotic tissue atwound edge prevents migration of newepithelium to cover wound• Debridement results in recruitment ofplatelets, release of PDGF, other plateletderivedfactors– Converts chronic wound to acute wound

Special considerations forpatients with ulcers and CLI• When to debride?• How much?• What about eschar?

When to debride?• In non-revasc pt,keep debridement toremoval of loose orinfected tissue• Once perfusionimproved, aggressivedebr warranted

How much to debride?

What about eschar?• Leave firmly adherenteschar in place• When edges separatefrom surroundingskin/wound, indicatestissue growthunderneath• Proceed with debrprimarily at edges

The necrotic toe

Wound bacterial load: CriticallyColonized Wounds• Debridement• Exudate management• Topical antimicrobials• Systemic antibiotics

Wound bacterial load• Bacterial count >10,000 CFUs of following speciessignificantly reduced wound closure– E. coli– Enterobacter– Enterococcus– Morganella– Pseudomonas– B-hemolytic strep• Relative risk of non-closure– Cell therapy group RR 1.4– Vehicle control group RR 5.4

• Bacteria on a surfacemultiply and secretepolysaccharide substancethat envelopes colony• Increases resistance toantibiotics, physicalstresses, endogenousdefense systems• Resistant to topicallyapplied agentsBiofilm infections

Biofilm/bacterial burden

Debridement for biofilm control

Wound bacteria data - chronicVLU• In chronic non-healers not responding tocompression, biopsies obtained for culture in45 patients– 48% ORSA– 22% pseudomonas• Most were treated with topical silver prior tobiopsy• Systemic antibiotics based on culture &sensitivities required

Topical antimicrobials• Iodine• Dakins• Silver– Acticoat• Hydrofera blue• Other• Studies have notidentified any in vivoreduction in bacterialload or improvementin healing rates

Vulcan trial• Michaels et al Br J Surg 2010;97:459• 213 patients with venous ulcers randomized• Silver donating dressings– Acticoat, Aquacel, Contreet• Non-silver donating dressings• All rec’d multilayer compression, other standardsof VLU care

Vulcan: results• No difference in 12 weeks healing rates• No difference in QOL assessments• Did not report incidence of wound infection• Cost-efficacy better for non-silvercontaining dressings

What to put on the wound?• Over 5000 dressing products available forcovering wounds• Tremendous lack of comprehensiveresearch on most• Minimal regulatory requirements forapproval of dressing products• Key concept is moist wound healing andmanagement of wound exudate

Exudate ManagementWound Fluid– Acute stimulates cell proliferation– Chronic - contributes to delayed healing• increased levels of MMP’s whichdegrades the extracellular matrix• selectively inhibits proliferating cells

Demonstrated effects of chronicwound fluid• Inhibits migration of fibroblasts• Inhibits division and proliferation offibroblasts and epithelial cells• Contains proteases that break downextracellular matrix proteins

Exudate ManagementChronic Wound FluidBacterialBurdenMicrobialManagementEdemaCompressionBreakdown ofNecrotic tissueDebridementGoal to remove excess wound fluid from wound/skin area

Exudate Management:DressingsNone Low Moderate Heavy

Hydrogels• Gel form of saline• Supply moisture todry wounds• Gel or impregnatedgauze• Use for diabetic footulcers, arterial ulcersif no infection ornecrotic tissue

Hydrocolloids• Provide barrier ifmechanical shear stressan issue• Small amount ofabsorptive capability• Assist with debridement• Use for pressure ulcers,some traumatic wounds

Alginates, Hydrofibers• Higher absorptivecapability• Turn into gel whenactivated by moisture• Prevent skin maceration• Use in more exudativewounds, VLUs undercompression

Foams, Specialty absorbents• High absorptivecapacity• Wick exudate awayfrom wound surface• Large, uncontrolledheavily draining VLUs

Other situations• Eschar• Debriding agents• Negative pressuredevices

Negative pressure compared tomoist wound therapy for DFUs• Blume et al• Daibetes Care2008;31:631-6• Randomized 342patients with DFUs toVAC compared tohydrogel or alginate• % closure at 16weeks45403530252015105043%VAC29%MWCP = 0.007

Summary• Determine underlyingcauses of wound• Consider ways toeliminateinflammation• Debride• Control bacterial load• Dressing based onspecific wound needs