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Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

Leg ulcer -- venous

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

About this topic

Have I got the right topic?

Age from 16 years onwards This guidance is based on the clinical practice guideline, 'The management of patients with venous leg ulcers', produced by the Royal College of Nursing institute (1998). This guidance covers the management of venous leg ulcers: assessment, cleansing, debridement, dressing, compression therapy, and preventing recurrence. Management of infection is covered, and complications such as pain and associated dermatitis are discussed. This guidance does not cover the management of leg ulcers with an arterial component or skin ulcers due to pressure. There are separate CKS topics on Diabetes Type 1 and 2 -- foot disease and Palliative care -- malignant ulcer of the skin. The target audience for this guidance is healthcare professionals working within the NHS in England, and providing first contact or primary health care. Patient information from NHS Direct is intended to be printed and given to people with this condition, and the Shared decision making sections are designed to provide a focus for discussion during the consultation about the treatment options.

Changes

Version 1.0.0, revision planned in 2007. Last revised in November 2004 January 2007 -- antibiotic prescriptions for infected leg ulcers updated. Issued in January 2007.

Previous changes

October 2005 -- minor technical update. Issued in November 2005. August 2004 -- written. Validated in September 2004 and issued in November 2004.

Update

New evidence

Evidence-based guidelines No new evidence-based guidelines since 1 March 2007. HTAs (Health Technology Assessments) No new HTAs since 1 March 2007. Economic appraisals No new economic appraisals relevant to England since 1 March 2007. Systematic reviews and meta-analyses A systematic review has been published since the last revision of this topic. · Palfreyman, S., Nelson, E.A., and Michaels, J.A. (2007) Dressings for venous leg ulcers: systematic review and meta-analysis. British Medical Journal Epub ahead of print. [Abstract] Primary evidence No new high quality randomized controlled trials since 1 March 2007.

New policies

No new national policies or guidelines since 1 March 2007.

New safety alerts

No new safety alerts since 1 March 2007.

Changes in product availability

No changes in product availability since 1 March 2007. This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

Concise knowledge for clinical scenarios

Which scenario?

· · · · · Uncomplicated venous leg ulcer: covers the intial management of of simple venous leg ulcers (with or without slough) that are not infected and do not have heavy exudate or odour. Leg ulcer with heavy exudate: covers the initial management of venous leg ulcers with heavy exudates or associated odour. Infected venous leg ulcer: covers the management of venous leg ulcers that show clinical signs and symptoms of infection. 12 week follow up assessment: covers the formal reassessment of venous leg ulcers. This should be carried out 12 weeks after the start of treatment, and every 12 weeks thereafter until healed. Healed venous leg ulcer: covers measures to prevent recurrence of venous ulcers.

Which therapy?

Assess the ulcerated area

· · · Record length and width of ulcer: trace the margins or photograph. Document the ulcer site: appearance of the ulcer edge, ulcer base, and surrounding skin. Measure the ankle brachial pressure index (ABPI).

Clean and dress the leg ulcer

· · · · · · Consider bed rest or leg elevation to reduce oedema before applying compression bandages. Measure ankle circumference 2 cm above the malleolus. Wash leg ulcers with clean tap water and dry carefully. Dress the wound with a low-adherent dressing. Apply 4-layer graduated compression bandaging. For active people or people unable to tolerate 4-layer bandaging, consider using 2-layer shortstretch bandaging.

Manage associated symptoms

· · · Offer oral analgesia such as paracetamol for associated pain. Consider topical analgesia if there is pain during dressing changes. Routine wound swabs are not recommended. Only use if there is evidence of clinical infection.

Should I refer or investigate?

Refer?

· ABPI less than 0.8: assume to have arterial disease, and refer to a vascular clinic for further assessment. Compression bandaging in such instances may further compromise arterial blood supply, and should be generally avoided. ABPI less than 0.5: urgent vascular referral. Compression bandaging in such instances should be avoided. Suspected malignancy, or if the diagnosis is uncertain (e.g. if the ulcer is not healing or has an atypical appearance or distribution). Acute ischaemic changes as a consequence of compression bandaging. Rapidly deteriorating ulcer. Non-healing ulcer after 12 weeks of adequate treatment. Pain management is inadequate. Healed ulcers with a view to venous surgery if appropriate.

· · · · · · ·

Investigate?

Rule out an arterial component.

· · Check pedal pulses, as they may indicate arterial insufficiency. Measure the ankle brachial pressure index (ABPI).

Other investigations to consider

· Full blood count to check for anaemia, infection.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· · · ·

Erythrocyte sedimentation rate, C-reactive protein: inflammatory markers. Fasting blood glucose and urinalysis to screen for diabetes mellitus. Urea, electrolytes, and creatinine to check for renal impairment. Wound swab only if clinical evidence of infection: pyrexia, increasing pain, enlarging ulcer or cellulitis.

Follow-up advice

· · Re-dress the leg ulcer with compression bandages every week. Reassess ulcers after 12 weeks and every 12 weeks thereafter until healed. o Reasses Doppler ABPI at 12 weeks if the ulcer is not fully healed or is deteriorating. o Refer complications such as non-healing ulcers after 12 weeks of adequate treatment. o Refer if suspected malignancy, or if the diagnosis is uncertain (e.g. if the ulcer is not healing or has an atypical appearance or distribution). Regularly assess concordance with treatment, and the effect of pain and mobility on quality of life. Provide written patient information. People are more likely to comply with treatment regimes if they are fully informed of the rationale and options for their management. Give general health promotion advice regarding regular walking and mobility, avoiding prolonged standing, leg elevation when immobile, stopping smoking, and good foot-care. Recommend graduated compression stockings for at least 5 years after ulcer healing, in order to minimize the risk of recurrence.

· · · ·

Prescriptions

15g size: Aquaform hydrogel

Age from 16 years onwards · · · AquaForm Hydrogel dressing. Apply to dry sloughy wounds when required to help autolytic debridement. Supply 4 15g packs. NHS Cost £7.20 Licensed use: no

15g size: Granugel hydrogel

Age from 16 years onwards · · · Granugel Hydrocolloid Gel dressing. Apply to dry sloughy wounds when required to help autolytic debridement. Supply 4 15g tubes. NHS Cost £7.92 Licensed use: no

15g size: Intrasite hydrogel

Age from 16 years onwards · · · IntraSite Gel dressing. Apply to dry sloughy wounds when required to help autolytic debridement. Supply 4 15g sachets. NHS Cost £8.24 Licensed use: no

15g size: Nu-Gel hydrogel

Age from 16 years onwards · · · Nu-Gel dressing. Apply to dry sloughy wounds when required to help autolytic debridement. Supply 4 15g packs. NHS Cost £7.72 Licensed use: no

15g size: Purilon hydrogel

Age from 16 years onwards · · · Purilon Gel dressing. Apply to dry sloughy wounds when required to help autolytic debridement. Supply 4 15g packs. NHS Cost £7.92 Licensed use: no

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

8g size: Intrasite hydrogel

Age from 16 years onwards · · · IntraSite Gel dressing. Apply to dry sloughy wounds when required to help autolytic debridement. Supply 4 8g sachets. NHS Cost £6.12 Licensed use: no

8g size: Purilon hydrogel

Age from 16 years onwards · · · Purilon Gel dressing. Apply to dry sloughy wounds when required to help autolytic debridement. Supply 4 8g packs. NHS Cost £6.00 Licensed use: no

25g size: Intrasite hydrogel

Age from 16 years onwards · · · IntraSite Gel dressing. Apply to dry sloughy wounds when required to help autolytic debridement. Supply 4 25g sachets. NHS Cost £12.20 Licensed use: no

Ankle circumference <18cm: Profore kit

Age from 16 years onwards · · · Profore multi-layer compression bandage kit up to 18cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £9.41 Licensed use: no

Ankle circumference 18-25cm: Ultra four kit

Age from 16 years onwards · · · Ultra Four multi-layer compression bandage kit 18cm-25cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £6.16 Licensed use: no

Ankle circumference 18-25cm: K-Four kit

· · Age from 16 years onwards Advice: Use the following information to write a prescription: supply one K-Four multilayer compression bandaging kit for ankle circumference 18-25cm. Follow the instructions given inside the pack. (Price £6.55)

Ankle circumference 18-25cm: System 4 kit

· · Age from 16 years onwards Advice: Use the following information to write a prescription: supply one System 4 multilayer compression bandaging kit for ankle circumference 18-25cm. Follow the instructions given inside the pack. (Price £8.15)

Ankle circumference 18-25cm: Profore kit

Age from 16 years onwards · · · Profore multi-layer compression bandage kit 18cm-25cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £8.77 Licensed use: no

Ankle circumference 25-30cm: Profore kit

Age from 16 years onwards · Profore multi-layer compression bandage kit 25cm-30cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· ·

NHS Cost £7.27 Licensed use: no

Ankle circumference >30cm: Profore kit

Age from 16 years onwards · · · Profore Lite multi-layer compression bandage kit. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £10.89 Licensed use: no

Multi-therapy: 2-layer dressing: Actiban short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Actiban short-stretch 10cm

Age from 16 years onwards · · · Actiban bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £20.40 Licensed use: no

Multi-therapy: 2-layer dressing: Actico short-stretch bandage + wadding

Patient information: Follow manufacturers' instructions for applying two layer compression bandaging.

Actico short-stretch 10cm

Age from 16 years onwards · · · Actico bandage 10cm. Use for two-layer compression bandaging. Supply 6 6m bandages. NHS Cost £18.60 Licensed use: no

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Multi-therapy: 2-layer dressing: Comprilan short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Comprilan short-stretch 10cm

Age from 16 years onwards · · · Comprilan bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £19.98 Licensed use: no

Multi-therapy: 2-layer dressing: Rosidal K short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Rosidal K short-stretch 10cm

Age from 16 years onwards · · · Rosidal K bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £20.16 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Multi-therapy: 2-layer dressing: Silkolan short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Silkolan short-stretch 10cm

Age from 16 years onwards · · · Silkolan bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £21.72 Licensed use: no

Wound contact layer

Age from 16 years onwards This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· · ·

Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Proguide (Red) 2-layer kit: ankle circumference 18-22cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 18cm-22cm ankle circumference. Follow the instructions given inside this pack. Supply 6 kits. NHS Cost £54.42 Licensed use: no

Proguide (Yellow) 2-layer kit: ankle circumference 22-28cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 22cm-28cm ankle circumference. Follow the instructions given inside this pack. Supply 6 kits. NHS Cost £57.42 Licensed use: no

Proguide (Green) 2-layer kit: ankle circumference 28-32cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 28cm-32cm ankle circumference. Follow the instructions given inside this pack. Supply 6 kits. NHS Cost £60.36 Licensed use: no

Paracetamol tablets: 1g up to four times a day

Age from 16 years onwards · · · · Paracetamol 500mg tablets. Take two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours. Supply 100 tablets. NHS Cost £0.75 OTC Cost £1.32 Licensed use: yes

Drug rationale

Drugs not included

· · · Hydrogel sheets, pastes, and products that require premixing are not offered. Low-adherent dressings other than knitted viscose primary dressings are not required as the wound contact layer for uncomplicated ulcers. Adhesive bordered dressings are not offered, as people with venous leg ulcer tend to have sensitive skin, and because dressings under high compression multi-layer bandages do not tend to slip. Multi-layer compression bandaging: individual bandages for multi-layer bandaging are offered as part of a kit and not separately in this scenario. Compression hosiery is reserved for people with healed ulcers, to prevent recurrence.

· ·

Drugs included

· · Ready-mixed hydrogel dressings are offered to help with desloughing ulcers. A range of sizes and application packs appropriate for venous leg ulcers are offered. Multi-layer compression bandaging: 4-layer kits (K-Four®, Profore®, System 4®, UltraFour®) are offered, appropriate to ankle circumference. They contain: o Low-adherent dressings for the wound contact layer. o Wadding bandages (the first layer applied), which are used to reshape the leg in people with a narrow ankle circumference. o Light support bandages, used at layers 2 and 3. o Cohesive bandages, used at layer 4.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

·

·

Two-layer short-stretch bandaging may be preferred in an active, younger person, or if concordance with 4-layer bandaging is a problem. These are generally offered as a multiple-item prescription containing: o Low-adherent dressings: knitted viscose primary dressings (e.g. N-A Dressings®) are suitable for a wound contact layer beneath compression bandaging. o Wadding bandages (the first layer applied) are used to reshape the leg in people with a narrow ankle circumference. o Short-stretch compression bandages are the second layer applied. o Note: Proguide® is the only 2-layer system available as a kit. Paracetamol is offered as a first-line analgesic. Manage pain according to response and associated comorbidities.

Shared decision making

· · · · A leg ulcer is normally washed with tap water before a dressing is put on. A nurse will usually apply compression bandages over the dressing. This is the most important part of treatment to help the ulcer to heal. The dressing and bandaging are normally changed every week. Other measures that may promote healing include: o Keep as active as possible. o Do not stand for long periods. o If possible, elevate your leg when you are resting. o If you smoke, try to stop. Painkillers may be helpful if the ulcer is painful. Once the ulcer has healed, if you wear a support stocking each day it will help to prevent a recurrence.

· ·

Which therapy?

Assess the ulcerated area

· · · Record length and width of ulcer: trace the margins or photograph. Document the ulcer site: appearance of the ulcer edge, ulcer base, and surrounding skin. Measure the ankle brachial pressure index (ABPI).

Clean and dress the wound

· · · Measure ankle circumference 2 cm above the malleolus. Wash leg ulcers with clean tap water and dry carefully. Compression is the mainstay of treatment, as a reduction in oedema will reduce subsequent exudate formation. If exudate is not controlled by compression: o For sloughy wounds consider an alginate dressing. o For 'clean' wounds use a polyurethane foam dressing. o If there is associated odour, consider an odour absorbent dressing.

Apply compression bandaging

· · · Consider bed rest or leg elevation to reduce oedema before applying compression bandages. Apply 4-layer graduated compression bandaging. For active people or people unable to tolerate 4-layer bandaging, consider using 2-layer shortstretch bandaging.

Manage associated symptoms

· · · · · Offer oral analgesia such as paracetamol for associated pain. Consider topical analgesia if there is pain during dressing changes. Routine wound swabs are not recommended. Only use if there is evidence of clinical infection. Involve other health professionals. If available, consider dermatology specialist nurses, community leg-ulcer clinics, and leg-ulcer nurse specialists. Ensure direct access to specialised services for the management of specific complications.

Should I refer or investigate?

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

Refer?

· ABPI less than 0.8: assume to have arterial disease, and refer to a vascular clinic for further assessment. Compression bandaging in such instances may further compromise arterial blood supply, and should be generally avoided. ABPI less than 0.5: urgent vascular referral. Compression bandaging in such instances should be avoided. Suspected malignancy, or if the diagnosis is uncertain (e.g. if the ulcer is not healing or has an atypical appearance or distribution). Acute ischaemic changes as a consequence of compression bandaging. Rapidly deteriorating ulcer. Non-healing ulcer after 12 weeks of adequate treatment. Pain management inadequate. Healed ulcers with a view to venous surgery if appropriate.

· · · · · · ·

Investigate?

Rule out an arterial component.

· · Check pedal pulses, as they may indicate arterial insufficiency. Measure the ankle brachial pressure index (ABPI).

Other investigations to consider

· · · · · Full blood count to check for anaemia, infection. Erythrocyte sedimentation rate, C-reactive protein: inflammatory markers. Fasting blood glucose and urinalysis to screen for diabetes mellitus. Urea, electrolytes, and creatinine to check for renal impairment. Wound swab only if clinical evidence of infection: pyrexia, increasing pain, enlarging ulcer, or cellulitis

Follow-up advice

· · Re-dress leg ulcer with compression bandages every week. Reassess ulcers after 12 weeks and every 12 weeks thereafter until healed. o Reasses Doppler ABPI at 12 weeks if the ulcer is not fully healed or is deteriorating. o Refer complications such as non-healing ulcers after 12 weeks of adequate treatment. o Refer if suspected malignancy, or if the diagnosis is uncertain (e.g. if the ulcer is not healing or has an atypical appearance or distribution). Regularly assess patient concordance with treatment, and the effect of pain and mobility on quality of life. Provide written patient information. People are more likely to comply with treatment regimes if they are fully informed of the rationale and options for their management. Give general health promotion advice regarding regular walking and mobility, avoiding prolonged standing, leg elevation when immobile, stopping smoking, and good foot-care. Recommend graduated compression stockings for at least 5 years after ulcer healing, in order to minimise the risk of recurrence.

· · · ·

Prescriptions

5cmx5cm Allevyn dressing

Age from 16 years onwards · · · Allevyn dressing (non-adhesive) 5cm x 5cm square. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £5.40 Licensed use: no

5cmx7.5cm Advazorb dressing

Age from 16 years onwards · · · Advazorb dressing 5cm x 7.5cm rectangular. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £2.25 Licensed use: no

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

6cmx6cm Curafoam Plus dressing

Age from 16 years onwards · · · Curafoam Plus dressing 6cm x 6cm square. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £5.30 Licensed use: no

10cmx10cm Advazorb dressing

Age from 16 years onwards · · · Advazorb dressing 10cm x 10cm square. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £4.00 Licensed use: no

10cmx10cm Curafoam Plus dressing

Age from 16 years onwards · · · Curafoam Plus dressing 10cm x 10cm square. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £8.25 Licensed use: no

10cmx10cm Allevyn dressing

Age from 16 years onwards · · · Allevyn Adhesive dressing 10cm x 10cm square. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £10.65 Licensed use: no

10cmx10cm Biatain non-adhesive dressing

Age from 16 years onwards · · · Biatain Non-Adhesive dressing 10cm x 10cm square. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £10.20 Licensed use: no

11cmx11cm Tielle Plus dressing

Age from 16 years onwards · · · Tielle Plus Borderless dressing 11cm x 11cm square. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £14.65 Licensed use: no

10cmx10cm Lyofoam C odour absorbent foam/charcoal dressing

Age from 16 years onwards · · · Lyofoam C dressing 10cm x 10cm. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £13.45 Licensed use: no

5cmx5cm Curasorb dressing

Age from 16 years onwards · · · Curasorb dressing 5cm x 5cm. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £3.45 Licensed use: no

5cmx5cm Sorbsan dressing

Age from 16 years onwards This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· · ·

Sorbsan dressing 5cm x 5cm. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 1 box of ten dressings. NHS Cost £7.40 Licensed use: no

7.5cmx12cm Kaltostat dressing

Age from 16 years onwards · · · Kaltostat dressing 7.5cm x 12cm. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £8.85 Licensed use: no

10cmx10cm Curasorb dressing

Age from 16 years onwards · · · Curasorb dressing 10cm x 10cm. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £7.30 Licensed use: no

10cmx10cm Sorbalgon dressing

Age from 16 years onwards · · · Sorbalgon dressing 10cm x 10cm. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £7.50 Licensed use: no

10cmx10cm Sorbsan dressing

Age from 16 years onwards · · · Sorbsan dressing 10cm x 10cm. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 1 box of ten dressings. NHS Cost £7.75 Licensed use: no

10cmx10cm Algisite M dressing

Age from 16 years onwards · · · Algisite M dressing 10cm x 10cm. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £8.15 Licensed use: no

10cmx10cm Melgisorb dressing

Age from 16 years onwards · · · Melgisorb dressing 10cm x 10cm. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £8.20 Licensed use: no

10cmx10cm Carboflex odour absorbent charcoal dressing

Age from 16 years onwards · · · Carboflex dressing 10cm x 10cm. Apply directly to the venous ulcer to absorb excess exudate underneath compression bandages. Supply 5 dressings. NHS Cost £13.70 Licensed use: no

Ankle circumference <18cm: Profore kit

Age from 16 years onwards · Profore multi-layer compression bandage kit up to 18cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· ·

NHS Cost £9.41 Licensed use: no

Ankle circumference 18-25cm: Ultra four kit

Age from 16 years onwards · · · Ultra Four multi-layer compression bandage kit 18cm-25cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £6.16 Licensed use: no

Ankle circumference 18-25cm: K-Four kit

· · Age from 16 years onwards Advice: Use the following information to write a prescription: supply one K-Four multilayer compression bandaging kit for ankle circumference 18-25cm. Follow the instructions given inside the pack. (Price £6.55)

Ankle circumference 18-25cm: System 4 kit

· · Age from 16 years onwards Advice: Use the following information to write a prescription: supply one System 4 multilayer compression bandaging kit for ankle circumference 18-25cm. Follow the instructions given inside the pack. (Price £8.15)

Ankle circumference 18-25cm: Profore kit

Age from 16 years onwards · · · Profore multi-layer compression bandage kit 18cm-25cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £8.77 Licensed use: no

Ankle circumference 25-30cm: Profore kit

Age from 16 years onwards · · · Profore multi-layer compression bandage kit 25cm-30cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £7.27 Licensed use: no

Ankle circumference >30cm: Profore kit

Age from 16 years onwards · · · Profore Lite multi-layer compression bandage kit. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £10.89 Licensed use: no

Multi-therapy: 2-layer dressing: Actiban short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

Actiban short-stretch 10cm

Age from 16 years onwards · · · Actiban bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £20.40 Licensed use: no

Multi-therapy: 2-layer dressing: Actico short-stretch bandage + wadding

Patient information: Follow manufacturers' instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Actico short-stretch 10cm

Age from 16 years onwards · · · Actico bandage 10cm. Use for two-layer compression bandaging. Supply 6 6m bandages. NHS Cost £18.60 Licensed use: no

Multi-therapy: 2-layer dressing: Comprilan short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Comprilan short-stretch 10cm

Age from 16 years onwards · · · Comprilan bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £19.98 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Multi-therapy: 2-layer dressing: Rosidal K short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

·

Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Rosidal K short-stretch 10cm

Age from 16 years onwards · · · Rosidal K bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £20.16 Licensed use: no

Multi-therapy: 2-layer dressing: Silkolan short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Silkolan short-stretch 10cm

Age from 16 years onwards · · · Silkolan bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £21.72 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Proguide (Red) 2-layer kit: ankle circumference 18-22cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 18cm-22cm ankle circumference. Follow the instructions given inside this pack. Supply 6 kits. NHS Cost £54.42 Licensed use: no

Proguide (Yellow) 2-layer kit: ankle circumference 22-28cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 22cm-28cm ankle circumference. Follow the instructions given inside this pack. Supply 6 kits. NHS Cost £57.42 Licensed use: no

Proguide (Green) 2-layer kit: ankle circumference 28-32cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 28cm-32cm ankle circumference. Follow the instructions given inside this pack. Supply 6 kits. NHS Cost £60.36 Licensed use: no

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

Paracetamol tablets: 1g up to four times a day

Age from 16 years onwards · · · · Paracetamol 500mg tablets. Take two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours. Supply 100 tablets. NHS Cost £0.75 OTC Cost £1.32 Licensed use: yes

Drug rationale

Drugs not included

· · · · Dressings that are not recommended for heavily exuding ulcers are not included. Cavity dressings are not offered. Low-adherent dressings other than knitted viscose primary dressings are not required as the wound contact layer for uncomplicated ulcers. Adhesive bordered dressings are not offered as people with venous leg ulcer tend to have sensitive skin, and because dressings under high compression multi-layer bandages do not tend to slip. Multi-layer compression bandaging: individual bandages for multi-layer bandaging are offered as part of a kit and not separately in this scenario. Compression hosiery is reserved for people with healed ulcers, to prevent recurrence.

· ·

Drugs included

· · · · Polyurethane foam dressings are useful for absorbing exudates from wounds and are suitable for a wound contact layer beneath compression bandaging. Alginate dressings are useful for wounds with heavy exudates and slough. Odour absorbent dressings may be useful if there is odour associated with the leg ulcer. Multi-layer compression bandaging: 4-layer kits (K-Four®, Profore®, System 4®, UltraFour®) are offered, appropriate to ankle circumference. They contain: o Low-adherent dressings for the wound contact layer. o Wadding bandages (the first layer applied), which are used to reshape the leg in people with a narrow ankle circumference. o Light support bandages, used at layers 2 and 3. o Cohesive bandages, used at layer 4. Two-layer short-stretch bandaging may be preferred in an active, younger person, or if concordance with 4-layer bandaging is a problem. These are generally offered as a multiple-item prescription containing: o Low-adherent dressings: knitted viscose primary dressings (e.g. N-A Dressings®) are suitable for a wound contact layer beneath compression bandaging. Note: use a foam dressing instead if this is more clinically appropriate. o Wadding bandages (the first layer applied) are used to reshape the leg in people with a narrow ankle circumference. o Short-stretch compression bandages, are the second layer applied. o Note: Proguide® is the only 2-layer system available as a kit. Paracetamol is offered as a first-line analgesic. Manage pain according to response and associated comorbidities.

·

·

Shared decision making

· · · · · A leg ulcer is normally washed with tap water before a dressing is put on. Sometimes dead tissue needs to be cleared from the wound before it is dressed. A nurse will usually apply compression bandages over the dressing. This is the most important part of treatment to help the ulcer to heal. The dressing and bandaging are normally changed every week. Other measures that may promote healing include: o Keep as active as possible. o Do not stand for long periods. o If possible, elevate your leg when you are resting. o If you smoke, try to stop.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· ·

Painkillers may be helpful if the ulcer is painful. Once the ulcer has healed, if you wear a support stocking each day it will help to prevent a recurrence.

Which therapy?

IMPORTANT: only take wound swabs and offer treatment if there is evidence of clinical infection (e.g. pyrexia, increasing pain, enlarging ulcer, or cellulitis). Routine wound swabs are not recommended.

Investigate cause of infection and start empirical therapy

· · · · · Offer empirical treatment with oral flucloxacillin 500 mg four times a day for 7 days. If the person is hypersensitive to penicillin, offer oral empirical treatment with erythromycin 500 mg four times a day for 7 days. Clean the ulcer and take a wound swab. Review after 3 days and after swab results are available. Start new antibiotic appropriate to sensitivities for 7 days.

Clean and dress the leg ulcer

· · · · · · · Consider bed rest or leg elevation to reduce oedema before applying compression bandages. Measure ankle circumference 2 cm above the malleolus. Wash leg ulcers with clean tap water and dry carefully. Dress the wound with a low-adherent dressing. Apply 4-layer graduated compression bandaging. For active people or people unable to tolerate 4-layer bandaging, use 2-layer short-stretch bandaging. Re-dress daily or on alternate days if there is evidence of infection, to avoid exudates seeping through.

Manage associated symptoms

· · · · Offer oral analgesia for associated pain. Consider topical analgesia if there is pain during dressing changes. Involve other health professionals. If available, consider dermatology specialist nurses and vascular teams, community leg-ulcer clinics and leg-ulcer nurse specialists. Ensure direct access to specialised services for the management of specific complications.

Practical prescribing points

For further information please see the Medicines Compendium (www.medicines.org.uk) or the British National Formulary (www.bnf.org).

Should I refer or investigate?

Refer?

· · Referral may be necessary if clinical infection does not improve with oral antibiotics or if there is rapid ulcer deterioration. Refer if suspected malignancy, or if the diagnosis is uncertain (e.g. if the ulcer is not healing or has an atypical appearance or distribution).

Investigate?

Other investigations to consider

· · · · Full blood count to check for anaemia. Erythrocyte sedimentation rate, C-reactive protein: inflammatory markers. Fasting blood glucose and urinalysis to screen for diabetes mellitus. Urea, electrolytes, and creatinine to check for renal impairment.

Follow-up advice

· · Review empirical treatment once the sensitivity of the infective organism is known. Re-dress daily or on alternate days if there is evidence of infection, to avoid exudates seeping through.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· · ·

Regularly assess patient concordance with treatment, and the effect of pain and mobility on quality of life. Provide written patient information. People are more likely to comply with treatment regimes if they are fully informed of the rationale and options for their management. Give general health promotion advice regarding regular walking and mobility, avoiding prolonged standing, leg elevation when immobile, stopping smoking, and good foot-care.

Prescriptions

Flucloxacillin capsules: 500mg four times a day

Age from 16 years onwards · · · Flucloxacillin 500mg capsules. Take one capsule four times a day for 7 days. Supply 28 capsules. NHS Cost £6.52 Licensed use: yes

Erythromycin e/c tablets: 500mg four times a day

Age from 16 years onwards · · · Erythromycin 250mg gastro-resistant tablets. Take two tablets four times a day for 7 days. Supply 56 tablets. NHS Cost £6.44 Licensed use: yes

Ankle circumference <18cm: Profore kit

Age from 16 years onwards · · · Profore multi-layer compression bandage kit up to 18cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £9.41 Licensed use: no

Ankle circumference 18-25cm: Ultra four kit

Age from 16 years onwards · · · Ultra Four multi-layer compression bandage kit 18cm-25cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £6.16 Licensed use: no

Ankle circumference 18-25cm: K-Four kit

· · Age from 16 years onwards Advice: Use the following information to write a prescription: supply one K-Four multilayer compression bandaging kit for ankle circumference 18-25cm. Follow the instructions given inside the pack. (Price £6.55)

Ankle circumference 18-25cm: System 4 kit

· · Age from 16 years onwards Advice: Use the following information to write a prescription: supply one System 4 multilayer compression bandaging kit for ankle circumference 18-25cm. Follow the instructions given inside the pack. (Price £8.15)

Ankle circumference 18-25cm: Profore kit

Age from 16 years onwards · · · Profore multi-layer compression bandage kit 18cm-25cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £8.77 Licensed use: no

Ankle circumference 25-30cm: Profore kit

Age from 16 years onwards

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· · ·

Profore multi-layer compression bandage kit 25cm-30cm ankle circumference. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £7.27 Licensed use: no

Ankle circumference >30cm: Profore kit

Age from 16 years onwards · · · Profore Lite multi-layer compression bandage kit. Follow the instructions given inside this pack. Supply 1 kit. NHS Cost £10.89 Licensed use: no

Multi-therapy: 2-layer dressing: Actiban short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Actiban short-stretch 10cm

Age from 16 years onwards · · · Actiban bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £20.40 Licensed use: no

Multi-therapy: 2-layer dressing: Actico short-stretch bandage + wadding

Patient information: Follow manufacturers' instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Actico short-stretch 10cm

Age from 16 years onwards · · · Actico bandage 10cm. Use for two-layer compression bandaging. Supply 6 6m bandages. NHS Cost £18.60 Licensed use: no

Multi-therapy: 2-layer dressing: Comprilan short-stretch bandage + wadding

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Comprilan short-stretch 10cm

Age from 16 years onwards · · · Comprilan bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £19.98 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Multi-therapy: 2-layer dressing: Rosidal K short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Rosidal K short-stretch 10cm

Age from 16 years onwards · · · Rosidal K bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £20.16 Licensed use: no

Multi-therapy: 2-layer dressing: Silkolan short-stretch bandage + wadding

Patient information: Follow manufacturers instructions for applying two layer compression bandaging.

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Use for two-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

Silkolan short-stretch 10cm

Age from 16 years onwards · · · Silkolan bandage 10cm. Use for two-layer compression bandaging. Supply 6 5m bandages. NHS Cost £21.72 Licensed use: no

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

Wound contact layer

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use for two-layer compression bandaging. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Proguide (Red) 2-layer kit: ankle circumference 18-22cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 18cm-22cm ankle circumference. Follow the instructions given inside this pack. Supply 6 kits. NHS Cost £54.42 Licensed use: no

Proguide (Yellow) 2-layer kit: ankle circumference 22-28cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 22cm-28cm ankle circumference. Follow the instructions given inside this pack. Supply 6 kits. NHS Cost £57.42 Licensed use: no

Proguide (Green) 2-layer kit: ankle circumference 28-32cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 28cm-32cm ankle circumference. Follow the instructions given inside this pack. Supply 6 kits. NHS Cost £60.36 Licensed use: no

Paracetamol tablets: 1g up to four times a day

Age from 16 years onwards · · · · Paracetamol 500mg tablets. Take two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours. Supply 100 tablets. NHS Cost £0.75 OTC Cost £1.32 Licensed use: yes

Drug rationale

Drugs not included

· Antibiotics other than flucloxacillin and erythromycin are not offered. An antistaphylococcal antibiotic is appropriate for empirical therapy. Review treatment when the results of microbiological investigation are available. Topical antibiotics should be avoided unless used under specialist recommendation against an identified microorganism, and for a short duration. Adhesive bordered dressings are not offered, as people with venous leg ulcer tend to have sensitive skin, and because dressings under high compression multi-layer bandages do not tend to slip. Multi-layer compression bandaging: individual bandages for multi-layer bandaging are offered as part of a kit and not separately in this scenario. Compression hosiery is reserved for people with healed ulcers, to prevent recurrence.

· ·

· ·

Drugs included

· Oral antibiotics are offered, but intravenous antibiotics may be required, depending on the severity of infection. o Flucloxacillin is offered for first-line empirical treatment of infection. o Erythromycin is offered as an alternative for people with penicillin hypersensitivity. Multi-layer compression bandaging: 4-layer kits (K-Four®, Profore®, System 4®, UltraFour®) are offered, appropriate to ankle circumference. They contain:

·

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

o o

·

·

Low-adherent dressings for the wound contact layer. Wadding bandages (the first layer applied), which are used to reshape the leg in people with a narrow ankle circumference. o Light support bandages, used at layers 2 and 3. o Cohesive bandages, used at layer 4. Two-layer short-stretch bandaging may be preferred in an active, younger person, or if concordance with 4-layer bandaging is a problem. These are generally offered as a multiple-item prescription containing: o Low-adherent dressings: knitted viscose primary dressings (e.g. N-A Dressings®) are suitable for a wound contact layer beneath compression bandaging. o Wadding bandages (the first layer applied) are used to reshape the leg in people with a narrow ankle circumference. o Short-stretch compression bandages are the second layer applied. o Note: Proguide® is the only 2-layer system available as a kit. Paracetamol is offered as a first-line analgesic. Manage pain according to response and associated comorbidities.

Shared decision making

· · · · · A leg ulcer is normally washed with tap water before a dressing is put on. A course of antibiotics is needed if the ulcer becomes infected. A nurse will usually apply compression bandages over the dressing. This is the most important part of treatment to help the ulcer to heal. The dressing and bandaging are normally changed every week -- but more frequently if the ulcer is infected. Other measures that may promote healing include: o Keep as active as possible. o Do not stand for long periods. o If possible, elevate your leg when you are resting. o If you smoke, try to stop. Painkillers may be helpful if the ulcer is painful. Once the ulcer has healed, if you wear a support stocking each day it will help to prevent a recurrence.

· ·

Which therapy?

Assess the ulcerated area

· · · Record length and width of ulcer: trace the margins or photograph. Document the ulcer site: appearance of the ulcer edge, ulcer base, and surrounding skin. Reasses ankle brachial pressure index (ABPI) at 12 weeks if the ulcer is not fully healed or is deteriorating.

Clean and dress the leg ulcer

· · · · · · Consider bed rest or leg elevation to reduce oedema before applying compression bandages. Measure ankle circumference 2 cm above the malleolus. Wash leg ulcers with clean tap water and dry carefully. Dress the wound with a low-adherent dressing. Apply 4-layer graduated compression bandaging. For active people or people unable to tolerate 4-layer bandaging, use 2-layer short-stretch bandaging.

Manage associated symptoms

· · Continue analgesia such as paracetamol for associated pain when required. Routine wound swabs are not recommended. Only use if there is evidence of clinical infection.

Should I refer or investigate?

Refer?

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· ·

Refer if suspected malignancy, or if the diagnosis is uncertain (e.g. if the ulcer is not healing or has an atypical appearance or distribution). Consider referral for healed ulcers, with a view to venous surgery if appropriate.

Investigate?

· Routine wound swabs are not recommended, and should be used only if there is evidence of clinical infection.

Follow-up advice

· · Re-dress the leg ulcer with compression bandages every week. Reassess ulcers after 12 weeks and every 12 weeks thereafter until healed. o Reasses Doppler ABPI at 12 weeks if the ulcer is not fully healed or is deteriorating. o Refer complications such as non-healing ulcers after 12 weeks of adequate treatment. o Refer if suspected malignancy, or if the diagnosis is uncertain (e.g. if the ulcer is not healing or has an atypical appearance or distribution). Regularly assess concordance with treatment, and the effect of pain and mobility on quality of life. Provide written patient information. People are more likely to comply with treatment regimes if they are fully informed of the rationale and options for their management. Give general health promotion advice regarding regular walking and mobility, avoiding prolonged standing, leg elevation when immobile, stopping smoking, and good foot-care. Recommend graduated compression stockings for at least 5 years after ulcer healing, in order to minimize the risk of recurrence.

· · · ·

Prescriptions

Wound contact layer: knitted viscose dressing 9.5cmx9.5cm

Age from 16 years onwards · · · Knitted viscose primary dressing BP type 1 - 9.5cm x 9.5cm. Use as the wound contact dressing. Supply 6 dressings. NHS Cost £1.98 Licensed use: no

Wadding layer for shaping the leg and for absorption

Age from 16 years onwards · · · K-Soft bandage 10cm. Apply as the first layer in multi-layer compression bandaging. Supply 6 3.5m bandages. NHS Cost £2.52 Licensed use: no

10cmx4.5m cotton+polyamide+elastane bandage

Age from 16 years onwards · · · Cotton, polyamide and elastane bandage 10cm. Follow the instructions given inside this pack. Supply 4 4.5m bandages. NHS Cost £3.96 Licensed use: no

K-Four #2 (K-lite 10cm bandage)

Age from 16 years onwards · · · K-Lite bandage 10cm. Follow the instructions given inside this pack. Supply 4 bandages. NHS Cost £3.84 Licensed use: no

Profore #2 (Soffcrepe 10cm bandage)

Age from 16 years onwards · · Profore #2 bandage 10cm. Follow the instructions given inside this pack. Supply 4 4.5m bandages. NHS Cost £4.96

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

·

Licensed use: no

System 4 #2 (Setocrepe 10cm bandage)

Age from 16 years onwards · · · Setocrepe bandage 10cm. Follow the instructions given inside this pack. Supply 4 4.5m bandages. NHS Cost £4.72 Licensed use: no

Ultra Four #2 (Ultra Lite 10cm bandage)

Age from 16 years onwards · · · K-Lite bandage 10cm. Follow the instructions given inside this pack. Supply 4 4.5m bandages. NHS Cost £3.68 Licensed use: no

10cmx6m elastomer+viscose type 3a bandage

Age from 16 years onwards · · · Elastomer and viscose bandage knitted compression type 3a - 10cm. Follow the instructions given inside this pack. Supply 4 6m bandages. NHS Cost £10.20 Licensed use: no

10cmx8.7m elastomer+viscose type 3a bandage

Age from 16 years onwards · · · Elastomer and viscose bandage knitted compression type 3a - 10cm. Follow the instructions given inside this pack. Supply 4 8.7m bandages. NHS Cost £8.52 Licensed use: no

K-four #3 (K-plus 10cm bandage)

Age from 16 years onwards · · · K-Plus bandage 10cm. Follow the instructions given inside this pack. Supply 4 bandages. NHS Cost £18.48 Licensed use: no

Profore #3 (Litepress 10cm bandage)

Age from 16 years onwards · · · Profore #3 bandage 10cm. Follow the instructions given inside this pack. Supply 4 8.7m bandages. NHS Cost £14.48 Licensed use: no

System 4 #3 (Elset 10cm bandage)

Age from 16 years onwards · · · Elset bandage 10cm. Follow the instructions given inside this pack. Supply 4 8m bandages. NHS Cost £13.04 Licensed use: no

Ultra Four #3 (Ultra plus 10cm bandage)

Age from 16 years onwards · · · K-Plus bandage 10cm. Follow the instructions given inside this pack. Supply 4 8.7m bandages. NHS Cost £8.20 Licensed use: no

Profore + (10cm bandage)

Age from 16 years onwards · Profore + bandage 10cm. Follow the instructions given inside this pack. Supply 4 3m bandages.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· ·

NHS Cost £13.60 Licensed use: no

10cmx2.5m cohesive type 3a bandage

Age from 16 years onwards · · · Elastomer and viscose bandage knitted compression type 3a - 10cm. Follow the instructions given inside this pack. Supply 6 2.5m bandages. NHS Cost £18.00 Licensed use: no

10cmx6m cohesive type 3a bandage

Age from 16 years onwards · · · Elastomer and viscose bandage knitted compression type 3a - 10cm. Follow the instructions given inside this pack. Supply 6 6m bandages. NHS Cost £17.10 Licensed use: no

10cmx6.3m cohesive type 3a bandage

Age from 16 years onwards · · · Elastomer and viscose bandage knitted compression type 3a - 10cm. Follow the instructions given inside this pack. Supply 6 6.3m bandages. NHS Cost £16.92 Licensed use: no

K-Four #4 (Ko-flex 10cm x 6m bandage)

Age from 16 years onwards · · · Ko-Flex bandage 10cm. Follow the instructions given inside this pack. Supply 6 bandages. NHS Cost £17.40 Licensed use: no

Profore #4 (Co-plus 10cmx2.5m bandage)

Age from 16 years onwards · · · Profore #4 bandage 10cm. Follow the instructions given inside this pack. Supply 6 2.5m bandages. NHS Cost £18.00 Licensed use: no

System 4 #4 (Coban 10cm x 6m bandage)

Age from 16 years onwards · · · Coban self-adherent bandage 10cm. Follow the instructions given inside this pack. Supply 6 6m bandages. NHS Cost £17.70 Licensed use: no

Ultra Four #4 (Ultra Fast 10cm x 6.3m bandage)

Age from 16 years onwards · · · Ultra Fast cohesive bandage 10cm. Follow the instructions given inside this pack. Supply 6 6.3m bandages. NHS Cost £16.92 Licensed use: no

Actico 10cmx6m bandage

Age from 16 years onwards · · · Actico bandage 10cm. Follow the instructions given inside this pack. Supply 4 6m bandages. NHS Cost £12.60 Licensed use: no

Actiban 10cmx5m bandage

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

Age from 16 years onwards · · · Actiban bandage 10cm. Follow the instructions given inside this pack. Supply 4 5m bandages. NHS Cost £13.60 Licensed use: no

Comprilan 10cmx5m bandage

Age from 16 years onwards · · · Comprilan bandage 10cm. Follow the instructions given inside this pack. Supply 4 5m bandages. NHS Cost £13.32 Licensed use: no

Rosidal K 10cmx5m bandage

Age from 16 years onwards · · · Rosidal K bandage 10cm. Follow the instructions given inside this pack. Supply 4 5m bandages. NHS Cost £13.44 Licensed use: no

Silkolan 10cmx5m bandage

Age from 16 years onwards · · · Silkolan bandage 10cm. Follow the instructions given inside this pack. Supply 4 5m bandages. NHS Cost £14.48 Licensed use: yes

Proguide (Red) 2-layer kit: ankle circumference 18-22cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 18cm-22cm ankle circumference. Follow the instructions given inside this pack. Supply 4 kits. NHS Cost £36.28 Licensed use: no

Proguide (Yellow) 2-layer kit: ankle circumference 22-28cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 22cm-28cm ankle circumference. Follow the instructions given inside this pack. Supply 4 kits. NHS Cost £38.28 Licensed use: yes

Proguide (Green) 2-layer kit: ankle circumference 28-32cm

Age from 16 years onwards · · · ProGuide multi-layer compression bandage kit 28cm-32cm ankle circumference. Follow the instructions given inside this pack. Supply 4 kits. NHS Cost £40.24 Licensed use: no

Drug rationale

Drugs not included

· Multi-layer compression bandages 4-layer kits are not offered, as the light support bandages are reusable and a full kit may not be required at each dressing change. However, wadding bandages and cohesive bandages are single-use dressings.

Drugs included

· · · Low-adherent wound contact dressing; knitted viscose dressing size 9.5 cm x 9.5 cm is offered. Wadding bandages are the first layer to be applied in multi-layer compression and are used to reshape the leg. Light support bandages are used at layers two and three in 4-layer compression. Profore +® is offered for use on larger limbs. The light support bandages are reusable, and washing instructions should be followed.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

· ·

Cohesive bandages are the outer layer of a 4-layer dressing; they adhere to themselves and cannot be reused. Short-stretch bandages are offered for use with wadding bandages in a 2-layer dressing for more active people who cannot tolerate 4-layer dressings.

Shared decision making

· · · · A leg ulcer is normally washed with tap water before a dressing is put on. A nurse will usually apply compression bandages over the dressing. This is the most important part of treatment to help the ulcer to heal. The dressing and bandaging are normally changed every week. Other measures that may promote healing include: o Keep as active as possible. o Do not stand for long periods. o If possible, elevate your leg when you are resting. o If you smoke, try to stop. Painkillers may be helpful if the ulcer is painful. Once the ulcer has healed, if you wear a support stocking each day it will help to prevent a recurrence.

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Which therapy?

· · · · · · Continue graduated compression stockings for at least 5 years after ulcer healing. Consider the use of lifelong compression stockings with 6-monthly Doppler ABPI checks, to reduce the risk of recurrence further. Offer the strongest compression with which the person can comply. Identify any at-risk areas early to prevent further skin breakdown, as chronic venous hypertension may result in delayed healing if the leg is injured. Give general health promotion advice regarding regular walking and mobility, avoiding prolonged standing, leg elevation when immobile, stopping smoking and foot-care. Encourage optimum nutrition and reduce obesity where appropriate.

Should I refer or investigate?

Refer?

· Consider referral for healed ulcers, with a view to venous surgery if appropriate.

Follow-up advice

· · Provide written patient information. People are more likely to comply with treatment regimes if they are fully informed of the rationale and options for their management. Give general health promotion advice regarding regular walking and mobility, avoiding prolonged standing, leg elevation when immobile, stopping smoking, and good foot-care.

Prescriptions

Class III knee-length stockings

Age from 16 years onwards · Compression hosiery class III below knee stocking circular knit standard stock size. One pair of circular knit, knee length class III compression stockings to be measured and fitted in the pharmacy. Supply 2 single stockings. NHS Cost £10.44 Licensed use: no Patient Information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.

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Class II knee-length stockings

Age from 16 years onwards · Compression hosiery class II below knee stocking circular knit standard stock size. One pair of circular knit, knee length class II compression stockings to be measured and fitted in the pharmacy. Supply 2 single stockings.

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NHS Cost £9.21 Licensed use: no Patient Information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.

Drug rationale

Drugs not included

· Class I light support stockings are not offered. Greater support is required for the prevention of recurrent venous leg ulcers.

Drugs included

· · Class II medium support below-knee stocking are offered. Class III strong support below-knee stockings are offered.

Shared decision making

· · · Once a venous leg ulcer has healed, if you wear a support stocking each day it will help to prevent a recurrence. Ideally, wear class III compression stockings. However, some people find class III stockings too tight, but class II may be fine. Other measures that may help prevent recurrences include: o Keep as active as possible. o Do not stand for long periods. o If possible, elevate your leg when you are resting. o If you smoke, try to stop. o If you are overweight, try to lose some weight.

Detailed knowledge about this topic

Goals and outcome measures

Goals

· · · · To provide optimal conditions for ulcer healing, including general health promotion and education To manage complications of venous leg ulcers such as oedema, infection, and contact dermatitis To identify possible arterial insufficiency that requires assessment and treatment in secondary care To minimize or prevent the recurrence of leg ulcers

Outcome measures

· · · Number of venous leg ulcers healed within 12 weeks. Number of healed leg ulcers within 12 months. Number of recurrent leg ulcers after 5 years.

Background information

What is it?

· Chronic venous insufficiency and venous hypertension result from damage to the valves in the veins of the leg and inadequate functioning of the calf muscle pump [Nelson et al, 2000]. This leads to oedema and skin breakdown. A leg ulcer may be defined as the 'loss of skin below the knee on the leg or foot, which takes more than six weeks to heal' [NHS CRD, 1997].

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How common is it?

· · Venous leg ulcers are a common, chronic, recurring condition. Venous leg ulcers have a prevalence estimated at 1.5­3 per 1000 of the UK population [NHS CRD, 1997].

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Prevalence increases with age, rising to 20 per 1000 aged over 80 years [Royal College of Nursing, 2000a]. The incidence of venous leg ulcers is expected to rise further, with demographic changes of increasing numbers of older people in the population. Incidence is spread evenly across different socio-economic groups, but ulcers take longer to heal and recurrence rates are higher in classes IV and V [SIGN, 1998]. Most people with ulceration (estimated at 80%) are managed solely in the community [SIGN, 1998]. Venous, stasis, or varicose ulcers represent 80­85% of all leg ulcers [Simon et al, 2004]. The economic cost of leg ulcers to the NHS is estimated at £300­£600 million a year [Simon et al, 2004].

How do I know my patient has a venous leg ulcer?

History Record any aspects of the past medical history that may suggest venous or non-venous disease. Table 1. Past medical history that may suggest venous disease or non-venous disease.

History suggesting venous disease

Varicose veins Proven deep vein thrombosis in the affected leg Phlebitis in the affected leg Previous fracture, trauma, or surgery Family history of venous disease Symptoms of venous insufficiency: leg pain, heavy legs, aching, itching, swelling, skin breakdown, pigmentation, and eczema.

[Royal College of Nursing, 2000a]

History suggesting arterial disease

Ischaemic heart disease Stroke Transient ischaemic attack Diabetes mellitus Peripheral vascular disease Intermittent claudication

Examination

· · · · · · Oedema of the lower leg. Varicose veins. Varicose eczema. Hyperpigmentation: haemosiderin deposition or iron pigments in the skin. Lipodermatosclerosis: dermatitis followed by induration and dermal fibrosis. Atrophie blanche: smooth, ivory-white plaques stippled with telangiectasia and surrounded by hyperpigmentation.

Investigations to exclude an arterial component to the ulcer

· · · · Venous, stasis, or varicose ulcers represent 80­85% of all leg ulcers [Simon et al, 2004]. The absence of pedal pulses may indicate arterial insufficiency; however, palpation alone is inadequate to rule this out. The ankle brachial pressure index (ABPI) is the most reliable way to detect arterial insufficiency [SIGN, 1998]. If ABPI is less than 0.8, assume arterial disease. Assessment of capillary refill.

Other investigations to consider

· · · · · Diabetes mellitus: fasting blood glucose and urinalysis. Renal function: urea, electrolytes, and creatinine [Royal College of Nursing, 2000b]. Anaemia: full blood count. Inflammatory disease: erythrocyte sedimentation rate (ESR) or C-reactive protein. Infection: full blood count, ESR. Swab if there is clinical evidence of infection, such as pyrexia, increasing pain, enlarging ulcer, and cellulitis [SIGN, 1998].

What are the risk factors for venous leg ulcer?

At least two causative factors can be identified in a third of leg ulcers [London and Donnelly, 2000]. Risk factors include: This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

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Previous history of venous leg ulcer Increasing age Obesity Immobility Peripheral oedema Varicose veins Deep venous thrombosis

What else might it be?

· Arterial ulcer has a punched-out appearance, with ischaemia and necrosis. This is typical in a person with atherosclerosis, with pale or blue, mottled, shiny, cold skin; prolonged capillary refill; nail dystrophy; reduced hair growth; and calf muscle wasting of the limb. Combined arterial and venous insufficiency may be seen in 10­20% of leg ulcers [SIGN, 1998]. Rheumatoid ulcer (vasculitic) is typically deep, well-demarcated and punched-out on the dorsum of foot or calf. People with rheumatoid arthritis might also have venous disease due to reduced mobility, neuropathy, and possibly impaired healing due to systemic corticosteroids. Systemic vasculitis often causes multiple leg ulcers that are necrotic and deep. There is usually an atypical distribution with vasculitic lesions elsewhere (e.g. nail-fold infarcts and splinter haemorrhages). This may be associated with systemic lupus erythematosus, scleroderma, polyarteritis nodosa, or Wegener's granulomatosis. Diabetic ulcer is typically on the foot over a bony prominence. This may have neuropathic, arterial, and/or venous components. Hypertensive ulcer (due to arteriolar occlusion) is painful with necrotic edges, and is usually sited on the lateral aspect of the lower leg. Malignant ulcer (due to basal or squamous cell carcinoma, melanoma, or Bowen's disease) are rare, but must be considered if ulceration does not respond to conventional treatment or if the appearance is unusual. Other possible causes include traumatic ulcer, sarcoidosis, tropical ulcer, or pyoderma gangrenosum.

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Complications and prognosis

Complications

· · · · Pain. Oedema. Immobility. Infection may present as inflammation, redness, purulent exudate, pyrexia, increased pain, or the person becoming systemically unwell [Royal College of Nursing, 2000a]. More than 80% of chronic leg ulcers may be colonized with bacteria such as Staphylococcus aureus and Pseudomonas aeruginosa [O'Meara and Ovington, 2002]. The presence of bacterial contamination (non-replicating micro-organisms on the surface) does not appear to affect ulcer healing [Royal College of Nursing, 1998; O'Meara and Ovington, 2002]. Contact dermatitis due to sensitivity to topical treatments. Quality of life and daily functioning: the negative impacts of chronic venous ulcers have been quoted in several studies [Budgen, 2004; Persoon et al, 2004] prescription costs of bandages and dressings, time off work, pain, psychological distress, loss of independence and social isolation [Simon et al, 2004].

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Venous ulcers may deteriorate quickly after presentation, and it is important for health professionals to act quickly to minimise venous insufficiency and aid the healing process.

Prognosis

· · · · Venous leg ulcers cause significant morbidity and reduction in quality of life. Twelve-month recurrence rates of 26­69% have been reported [Nelson et al, 2000]. Poor healing rates may be exacerbated by poor patient concordance with treatment regimes. Healing rates of 70% at 12 weeks have been achieved for small ulcers managed in specialist clinics [SIGN, 1998].

Management issues

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How is a venous leg ulcer assessed?

Initial assessment must exclude an arterial component to the ulcer, as compression bandaging may be inappropriate in such cases (see section on Ankle Brachial Pressure Index). · Assess features of the ulcerated area: o Serial measurement (length and width) is an indicator of the healing process. o Tracing of the margins and photography may be helpful. o Note the site of the ulcer (usually on the gaiter area of the leg, above the medial or lateral malleoli). o Assess the edge of the ulcer (shallow, punched out, rolling). o Assess the base of the ulcer (granulating, sloughy, necrotic) and its position. o Note the condition of surrounding skin, odour, and signs of infection. Offer a full examination, including pulse, blood pressure, and body mass index calculation. Measure the ankle brachial pressure index (ABPI) to help detect arterial insufficiency.

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[SIGN, 1998]

Ankle Brachial Pressure Index

· Ankle brachial pressure index (ABPI) is an objective assessment of the ulcer to identify arterial disease that may warrant referral to specialist vascular clinics. It provides an index of vessel competency by measuring the ratio of systolic blood pressure at the ankle to that in the arm, with a value of 1 being normal. It is important to be aware that ABPI measurements in patients with diabetes or atherosclerosis may not be reliable. Patients with these conditions may have falsely high (and misleading) pressure readings due to calcification of the vessels [SIGN, 1998]. In addition, microvascular disease associated with rheumatoid arthritis and systemic vasculitis cannot be assessed by ABPI. Therefore, if there is any doubt, such patients should be referred for specialist assessment. ABPI less than 0.5: arterial ulcers are likely and compression treatment is contraindicated, requiring urgent referral to a specialist vascular clinic for further assessment and possible revascularisation. ABPI between 0.5 and 0.8: assume that the person has arterial disease, and refer to a vascular clinic for further assessment. Compression bandaging in such instances may further compromise arterial blood supply, and should be generally avoided. However, if the ABPI is between 0.5 and 0.8, reduced compression can be used under strict supervision if the ulcer is clinically venous [SIGN, 1998; Royal College of Nursing, 2000b]. Clinical progress should be checked daily initially and compression modified according to clinical response. ABPI greater than 0.8: graduated compression bandages may be applied safely. Arterial disease may develop in people with venous disease, and health professionals should be aware that the ABPI may drop after the initial measurement [Royal College of Nursing, 2000a].

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Who needs to be referred to a specialist clinic for further assessment?

If there is any doubt about the cause of the ulcer, specialist assessment is recommended. · · · · · Suspected arterial ulcer: refer people with an ABPI of less than 0.8 for further assessment of arterial disease. If the ABPI is les than 0.5, refer urgently. Suspected malignant ulcer, a rapidly deteriorating ulcer, or diagnostic uncertainty: an atypical appearance or distribution of ulcers may require biopsy by dermatology. Suspected rheumatoid ulcer, or ulcers associated with systemic vascultitis. People with diabetes with an ulcer on the foot should be referred according to local arrangements. Note: acute ischaemic changes because of compression bandaging require urgent vascular referral.

How is a venous leg ulcer managed?

· · · · · · Involve appropriate health professionals, as a multi-disciplinary approach is often needed. Clean with water initially. Debridement is not usually necessary; however, it is important to maintain a moist wound environment and any slough should be removed. If surgical debridement is necessary, a topical anaesthetic may reduce associated pain. Apply a low-adherent dressing to the ulcer. Use compression bandaging to heal the leg ulcer. Reassess ulcers after 12 weeks and every 12 weeks thereafter until healed.

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Prevent recurrence of ulcers with compression stockings for at least 5 years.

Who should be involved in the management of venous leg ulcers?

Organization of care

· A co-ordinated multidisciplinary team approach is vital, as a variety of health professionals including practice nurses, district nurses, general practitioners, dermatology specialist nurses and teams, and vascular teams may be involved. Direct access to specialised hospital services is vital in the management of specific complications. Community leg-ulcer clinics may significantly improve healing and recurrence rates, and are more cost-effective when they have close liaison with secondary care [NHS CRD, 1997; SIGN, 1998]. Leg-ulcer nurse specialists in dedicated clinics can promote and maintain standards of care and cost-effectiveness, and provide training of hospital and community teams [Simon et al, 2004]. Future management should focus on preventing ulceration by identifying populations at risk [Simon et al, 2004].

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What treatments are available?

Cleansing and debridement

· · · Leg ulcers should first be washed in tap water, with bathing or showering at dressing changes, and dried carefully at each assessment [SIGN, 1998]. Saline washes are not better than tap water in cleaning soft tissue wounds [SIGN, 1998]. Antiseptics: there is no evidence that the use of antiseptics provides additional protection against infection [Royal College of Nursing, 2000a]. Research results are conflicting regarding the use of antimicrobial silver-based products to promote ulcer healing [O'Meara et al, 2000]. Debridement is only needed if slough or necrotic tissue is not removed from the ulcer by gentle washing. There is no clear evidence as to the optimal method for debridement. However, there is consensus that chemical agents such as iodine, acetic acid, hydrogen peroxide, or hypochlorite should not be used [Royal College of Nursing, 1998]. Sharp mechanical debridement (with a scalpel or sharp blade) may delay healing because of the risk of damaging healthy tissue and underlying blood vessels [Briggs and Nelson, 2003]. There is increasing use of maggots as biological debriding agents. However, there have been few controlled trials of their use in treating venous leg ulcers thus far [Royal College of Nursing, 1998; Courtenay et al, 2000]. LarvE (sterile maggots of Lucilia sericata, the common greenbottle) secrete a mixture of proteolytic enzymes that break down slough and necrotic tissue that is then ingested. This provides an improved environment for healing to take place, particularly where conventional treatments have failed [Thomas, 2004]. Referral to a specialist clinic or team for assessment may be necessary before this debridement method is initiated.

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Wound contact dressings

· · · Wound contact dressings can be changed weekly if there are no signs of infection. No specific dressing has been shown to improve healing rates in venous leg ulcer [SIGN, 1998; Bradley et al, 1999]. Uncomplicated venous ulcers require a simple low-adherent dressing. The dressing keeps the ulcer clean and allows excess exudate to be removed from the surface, reducing the risk of cross-infection and providing a moist micro-environment that promotes healing [Royal College of Nursing, 1998; Bradley et al, 1999]. Sloughy venous leg ulcers can be dressed with hydrogels to provide moisture that helps to liquefy slough [National Prescribing Centre, 1999]. Moderate to heavily exuding venous leg ulcers are less common: an alginate or foam dressing may be useful for absorbing exudates [National Prescribing Centre, 1999]. Painful ulcers may benefit from occlusive hydrocolloid or foam dressings [Royal College of Nursing, 2000a].

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Compression dressings

· Compression reduces high venous pressure in superficial veins, aiding venous return of blood to the heart by increasing the velocity of flow in the deep veins. It reduces oedema by reducing the pressure difference between the capillaries and the tissues. This promotes transport of metabolic products away from tissues, allowing ulcers to heal. A variety of high

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compression products are available, which seem to have similar efficacy in encouraging ulcer healing [Fletcher et al, 1997; NHS CRD, 1997; Cullum et al, 2001]. Below-knee graduated compression is the mainstay of treatment to improve venous return, and to reduce venous stasis and hypertension in uncomplicated venous leg ulcers. Graduated compression delivers the highest pressure at the ankle and gaiter area, and pressure progressively reduces towards the knee and thigh where less external pressure is needed.

Multi-layer compression

· High compression multi-layer bandaging is recommended (e.g. 4-layer or 3-layer bandaging). It has an improved ulcer healing rate compared to single-layer compression [NHS CRD, 1997; SIGN, 1998]. Trials generally favour multi-layer compression over 2-layer shortstretch bandages [SIGN, 1998]. However [Cullum et al, 2001], a recent study has found similar ulcer healing rates for both 4-layer and 2-layer short-stretch systems [Moffatt et al, 2003; Iglesias et al, 2004]. An appropriately trained person should apply high compression multi-layer bandaging, to avoid the risk of pressure ulceration over bony points [Simon et al, 2004]. Four-layer bandaging has sufficient absorption capacity to manage exudates, and to maintain application pressure for up to a week without needing re-application.

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Other compression methods

· Compression stockings provide graduated pressure that may be better tolerated than multilayer compression bandaging, but current evidence only supports the use of compression stockings for preventing ulcer recurrence [SIGN, 1998]. Intermittent pneumatic compression (IPC) may improve healing rates further [NHS CRD, 1997]. An air pump periodically inflates and deflates bladders incorporated into sleeves that envelop the affected limb [Mani et al, 2001]. A systematic review has recommended pneumatic compression devices for people with refractory oedema and significant ulceration, where a 6-month trial of standard compression has failed, or where people are unwilling or unable to tolerate this [Berliner et al, 2003]. Overall, however, a recent Cochrane review found only small trials of IPC, which were not directly comparable, with two trials reporting improved ulcer healing with IPC [Mani et al, 2001]. There was no clear evidence that IPC improves healing when compared with compression alone or when added to standard compression regimes, and further research is needed. Higher concordance rates with IPC than with other compression methods have been quoted in other studies [Berliner et al, 2003].

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Problems associated with compression

· · Adverse effects may include reduced blood supply to the skin and pressure damage. Arterial blood supply may be compromised. Compression bandages should be removed immediately and medical advice sought if the person experiences a change in foot colour and/or temperature, or increased pain. An acute ischaemic complication from compression should prompt an urgent vascular referral [Royal College of Nursing, 2000a]. Other contraindications to compression include active phlebitis, deep vein thrombosis, localized infection, or cellulitis [Ilsley, 2001]. Concordance with treatment should be assessed and encouraged regularly. Compression bandaging may be uncomfortable, and the needs of the individual must be addressed to ensure that the maximum level of compression with the most appropriate dressing is applied.

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Medicines to improve ulcer healing

· Pentoxifylline should be reserved for ulcers that do not heal with compression bandaging. A systematic review of eight randomized controlled trials suggests that pentoxifylline is more effective than placebo in reducing time to complete healing, and gives additional benefit to compression. However, further studies are required before pentoxifylline can be recommended as a routine treatment for venous leg ulcers [Jull et al, 2002]. Small trial evaluations of prostaglandins and aspirin have not shown convincing evidence of improved ulcer healing compared with no drug treatment [Simon et al, 2004].

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Other treatment options

· Superficial venous surgery may be considered in someone with chronic venous ulceration and superficial valvular incompetence, refractory to other treatment. This may involve removing superficial and/or perforating veins, or blocking incompetent veins by injecting irritant solution (sclerotherapy) [Nelson et al, 2000].

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Skin grafting may accelerate the speed of closure of the ulcer if other treatment modalities have failed. Pinch skin grafts (which provide epithelial islands from which epithelial growth may spread) have been highlighted in recent studies, and may be done in the community in association with multi-layer compression bandaging [Jones and Nelson, 2000; Simon et al, 2004]. Low-level laser therapy is sometimes used. However, there is no significant evidence of any benefit [Flemming and Cullum, 1999; Franek et al, 2002]. Combination laser and infrared light may promote healing further, but more research is needed [Flemming and Cullum, 1999]. Therapeutic ultrasound, electromagnetic therapy, electrical stimulation, and hyperbaric oxygen have similarly been suggested to stimulate healing. However, studies are generally small and the extent to which they have an impact is unclear [Fernandez-Chimeno et al, 2004; Flemming and Cullum, 2000; Flemming and Cullum, 2004; Kranke et al, 2004].

How are complications managed?

Leg oedema

· · Limb dependency, immobility, and oedema all contribute to venous hypertension [Simon et al, 2004]. Leg elevation encourages venous return and may reduce pain and leg swelling [Royal College of Nursing, 2000a]. Raising the legs above hip level for 30 minutes three to four times a day will allow swelling to subside and improve microcirculation in people with venous insufficiency. Placing several pillows under the bed mattress will assist leg elevation at night. However, there is insufficient evidence to recommend regular leg elevation as a routine intervention. Bed rest and elevation may reduce oedema of the ankle and leg before compression bandages are applied [SIGN, 1998].

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Infection

· · Antibiotics should be used only if there is evidence of cellulitis or active infection (e.g. pyrexia, increasing pain, enlarging ulcer, or cellulitis). The organisms most likely to be involved in cellulitis include Staphylococcus aureus, MRSA (methicillin-resistant Staphylococcus aureus), and Group A beta-haemolytic streptococci. Anaerobes may sometimes be involved. Empirical treatment with an anti-staphylococcal antibiotic should be used while awaiting wound swab results. Flucloxacillin 500 mg four times a day or erythromycin 500 mg four times a day for 7 days are suitable first choices for empirical therapy [McNulty, Personal Communication, 2004; HPA, 2006]. Clarithromycin 250­500 mg twice a day is an alternative for people who are unable to tolerate erythromycin. Ensure the person is reviewed after 3 days initially, and consider continuing antibiotics for a further 7 days after the first course, depending on the severity of infection and speed of response to treatment (see the CKS topic on Cellulitis). Oral or intravenous antibiotics may be required, depending on the severity of the infection. Routine wound swabs are not recommended, as there is no evidence for their use [SIGN, 1998]. Antibiotics have little effect on wound healing generally [O'Meara et al, 2000], so there is no value in using them to treat organisms that have colonized a wound but are not causing clinical signs or symptoms of infection. Topical antibiotics are frequent sensitizers and should be avoided if possible [SIGN, 1998]. Compression bandaging should not be used if there is evidence of cellulitis. Dressings should be reapplied daily or on alternate days to allow assessment of the infected area.

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Dermatitis

· · · · · Venous eczema is commonly associated with chronic venous ulcers. Typical features of venous eczema include diffuse erythema, scaling, haemosiderin pigmentation, and exudate with crusting if there is superadded infection. Frequent emollient application plus a short course of mild topical corticosteroid ointment should be the mainstay of treatment. Allergic contact dermatitis may complicate venous eczema in 60­80% of patients [SIGN, 1998]. Common sensitisers include wool alcohols, topical antibiotics, topical corticosteroids, cetylstearyl alcohols, parabens, and rubber mixes. See Table 2.

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Referral for dermatological patch testing may be appropriate if the dermatitis does not settle, or if there are concerns about sensitivity to a topical agent, dressing, or bandage used. Ideally a specific leg ulcer patch-test series should be used [SIGN, 1998]. People may become sensitized to components of their topical treatment at any time [Royal College of Nursing, 1998].

Pain

· Venous disease and venous leg ulcers are frequently painful. The pain experienced may be constant or intermittent. Constant pain can originate from vascular structures (superficial, deep phlebitis), pitting oedema, collagen (lipodermatosclerosis), or infection. Ulcer pain is often episodic and may be due to surgical or other debridement procedures. Intermittent pain is often related to dressing removal or recent applications of new dressings. Poor ulcer healing, arterial disease, or infection may also cause increased pain [Royal College of Nursing, 2000a], and this may be due to both inflammatory processes and nerve damage [Briggs and Nelson, 2003]. Between 17% and 65% of people with a leg ulcer experience severe or continuous pain with a major impact on quality of life [Briggs and Nelson, 2003]. Pain relief is important to maximise quality of life, to enable mobilization, and improve appetite. A pain assessment may be helpful, particularly for pain related to dressing adherence and wound cleansing. Some guidelines suggest that these should be performed routinely [Royal College of Nursing, 1998]. Leg elevation and compression may reduce pain associated with leg swelling and reduced venous return [Heinen et al, 2004]. Manage pain with oral paracetamol initially, and adjust treatment according to response and associated comorbidities. Topical analgesia may also be considered to reduce pain during debridement, although there is less evidence for these treatments [Briggs and Nelson, 2003], and use of topical analgesics on wounds is an off-licence indication.

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What follow-up is necessary?

· · · · Formal reassessment is recommended 12 weeks after treatment is commenced and at subsequent 12-week intervals, unless there are concerns of ulcer deterioration before this time. Serial measurement (length and width) is an indicator of the healing process. Tracing of the margins and photography may be helpful. Reassess the appearance of the ulcer: its edge (shallow, punched out, rolling), base (granulating, sloughy, necrotic), position, surrounding skin, odour, and signs of infection [SIGN, 1998]. Reassess the ankle brachial pressure index at 12 weeks if the ulcer is not fully healed or if it is deteriorating. Patient concordance with treatment and the effect of pain and mobility on quality of life should be assessed regularly. Written patient information should be provided when available, as people are more likely to comply with treatment regimes if they are fully informed of the rationale and options for their management.

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How can recurrence be prevented?

· · Twelve-month recurrence rates vary widely between different studies, and have been quoted as 26­69% [Nelson et al, 2000]. Graduated compression stockings should ideally be used for at least 5 years after ulcer healing, in order to minimise the risk of recurrence [SIGN, 1998]. Some health professionals advocate the use of lifelong compression stockings with 6-monthly Doppler ankle brachial pressure index checks, to reduce this risk further. Class III (high) compression stockings are associated with less recurrence than Class II (medium) compression stockings. However, the strong-support Class III stockings are less well tolerated [Royal College of Nursing, 2000a]. Identify any at-risk areas early to prevent further skin breakdown, as chronic venous hypertension may result in delayed healing if the leg is injured. Offer general health promotion advice regarding regular walking and mobility, avoiding prolonged standing, leg elevation when immobile, stopping smoking, and foot care. Encourage optimum nutrition and reduce obesity [Simon et al, 2004].

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Medicines to prevent recurrence

· Oxerutins or rutosides (Paroven capsules) decrease capillary permeability and have been suggested for reducing ulcer recurrence, but have not shown any greater effect in preventing recurrence compared with placebo [NHS CRD, 1997; Simon et al, 2004]. Oral zinc sulfate supplements are only useful to prevent recurrence of ulcers in people with low serum zinc levels. There is no evidence of benefit to support the general use of zinc supplements [Wilkinson and Hawke, 1998].

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Dressings information

Wound dressings

· · Dressings should keep the wound moist and warm to promote granulation. Granulation tissue is the outgrowth of new capillaries and connective tissue from the surface of an open wound. It is light red or dark pink in colour, soft to the touch, and 'bumpy' in appearance. It is very delicate and must be carefully supported while the wound heals. Knitted viscose dressings (e.g. N-A dressings, Tricotex) remain on the surface of a wound for several days, allowing exudate to pass through to an absorbent secondary dressing. Under high compression bandages, a knitted viscose dressing will suffice to produce a microenvironment to promote granulation. The absorbent layer above the dressing can be easily changed with minimal disturbance to the wound surface. Hydrogel dressings facilitate autolytic debridement of wounds and may be useful to maintain a moist wound environment in dry, sloughy wounds. Hydrocolloid dressings generally consist of a wafer constructed from a thin layer of polyurethane film (which is impermeable to water and microorganisms) with an adhesive that contains gelatine, pectin, and carboxymethylcellulose. Wound exudate combines with the ingredients of the adhesive to form a gel, which promotes moist wound healing. Foam dressings offer advantages in terms of speed of dressing change, comfort, and low odour potential compared with other dressing types. Foam dressings contain absorbent hydrophilic foam and allow evaporation of water through the backing to give extra potential for fluid management. They are generally comfortable, soft, and well tolerated. Alginate dressings may be useful to absorb exudates if the ulcer is sloughy.

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Allergens in dressings

· People with venous leg ulcers have high rates of skin sensitivity to allergens. Common allergens may be present in dressings for venous leg ulcers, as listed in Table 2. Table 2. Common allergens in the management of venous leg ulcers.

Common allergen

Lanolin Antibiotic Preservative Vehicle Adhesive Rubber Wool alcohols, amerchol L101 Neomycin, framycetin, bacitracin Parabens Cetyl alcohol, stearyl alcohol, cetylstearyl alcohol, cetostearyl alcohol Colophony/ester of rosin Mercapto/carba/thiuram mix

Potential source

Bath additives, creams, emollients, barrier preparations Tulle dressings, topical antibiotics Topical preparations, paste bandages Most creams, emulsifying ointment, and some paste bandages Adhesive-backed bandages and dressings, hydrocolloids Elastic bandages and supports, elastic stockings, latex gloves worn by carer Antiseptics and dressings Topical corticosteroid preparations Bath additives, emollients

Biocide Corticosteroid Fragrance

Chlorocresol, quinoline mix, chlorhexidine Tixocortal pivalate Fragrance mix/balsam of Peru

[Royal College of Nursing, 2000a]

Compression bandaging

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Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

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Multi-layer '4-layer' compression consists of four levels of bandage applied over a wound contact dressing in the following order: o Sub-compression wadding bandage. o Light support bandage, such as cotton crepe bandage. o Light compression bandage, such as knitted elastomer and viscose bandage. o Cohesive bandage (a bandage that adheres to itself to prevent movement of dressing). Two-layer compression is the application of a short-stretch bandage over a sub-compression wadding bandage, and may be useful for more active people or people for whom it is important to be able to wear their normal footwear. Only suitably trained practitioners should apply compression bandages. Inappropriate application may lead to uneven and inadequate pressures or too great a pressure being exerted, causing tissue damage or even necrosis.

Compression hosiery

Three different classes of stocking or graduated compression hosiery are available: Table 3. Compression hosiery.

Class

I II III · · · · ·

Type

Light Medium High

Ankle compression

14­17 mmHg 18­24 mmHg 25­35 mmHg

Indication

Superficial/early varicose veins, mild oedema, venous ulcers Moderate varicosities, post-operative prevention and treatment Severe varicose veins, ankle oedema, venous ulcers

Medium to high compression stockings are recommended for prophylaxis for 5 years after healing of a venous ulcer. A range of styles and colours are available to encourage concordance with prophylaxis. Compression hosiery is available in two lengths, 'below the knee' and 'thigh' length. Socks are available, as are suspenders for use with thigh-length stockings. Hosiery may have an open or closed toe. For open-toe hosiery, a heel may or may not be present. Graduated compression tights are not available for prescription on the NHS.

References

NHS staff in England can link, free of charge, from references to the full text journal articles by clicking on [NHS Athens Full-text]. You will need an NHS Athens password to access these resources. Click here for Athens registration. All references with links to [Free Full-text] are freely available online to users in England and Wales. This includes the full text of Department of Health papers and Cochrane Library reviews. 1 Berliner, E., Ozbilgin, B. and Zarin, D.A. (2003) A systematic review of pneumatic compression for treatment of chronic venous insufficiency and venous ulcers. Journal of Vascular Surgery 37(3), 539-544. Bradley, M., Cullum, N., Nelson, E.A. et al. (1999) Systematic reviews of wound care management: (2) dressings and topic agents used in the healing of chronic wounds. Health Technology Assessment 3(17 Pt 2), 1-143. [Free Full-text] Briggs, M. and Nelson, E.A. (2003) Topical agents or dressings for pain in venous leg ulcers (Cochrane Review). The Cochrane Library. Issue 1. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 24/02/2006]. [Free Full-text] Budgen, V. (2004) Evaluating the impact on patients of living with a leg ulcer. Nursing Times 100(7), 30-31. Courtenay, M., Church, J.C. and Ryan, T.J. (2000) Larva therapy in wound management. Journal of the Royal Society of Medicine 93(2), 72-74. [Free Full-text] Cullum, N., Nelson, E.A., Fletcher, A.W. and Sheldon, T.A. (2001) Compression for venous leg ulcers (Cochrane Review). The Cochrane Library. Issue 2. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 24/02/2006]. [Free Full-text]

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This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

Clinical Knowledge Summaries: Previous version ­ Leg ulcer - venous

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Fernandez-Chimeno, M., Houghton, P. and Holey, L. (2004) Electrical stimulation for chronic wounds (Protocol for a Cochrane Review). The Cochrane Library. Issue 1. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 21/02/2006]. [Free Full-text] Flemming, K. and Cullum, N. (1999) Laser therapy for venous leg ulcers (Cochrane Review). The Cochrane Library. Issue 1. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 21/02/2006]. [Free Full-text] Flemming, K. and Cullum, N. (2000) Therapeutic ultrasound for venous leg ulcers (Cochrane Review). The Cochrane Library. Issue 4. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 21/02/2006]. [Free Full-text] Flemming, K. and Cullum, N. (2004) Electromagnetic therapy for treating venous leg ulcers (Cochrane Review). The Cochrane Library. Issue 1. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 21/02/2006]. Fletcher, A., Cullum, N. and Sheldon, T.A. (1997) A systematic review of compression treatment for venous leg ulcer. British Medical Journal 315(7108), 576-580. [NHS Athens Full-text] Franek, A., Krol, P. and Kucharzewski, M. (2002) Does low output laser stimulation enhance the healing of crural ulceration? Some critical remarks. Medical Engineering & Physics 24(9), 607615. Heinen, M.M., van Achterberg, T., op Reimer, W.S. et al. (2004) Venous leg ulcer patients: a review of the literature on lifestyle and pain-related interventions. Journal of Clinical Nursing 13(3), 355-366. HPA (2006) Venous leg ulcers: infection diagnosis & microbiology investigation. Quick reference guide for primary care. Health Protection Agency. www.hpa.org.uk [Accessed: 16/01/2007]. [Free Full-text] Iglesias, C., Nelson, E.A., Cullum, N.A. and Torgerson, D.J. (2004) VenUS I: a randomised controlled trial of two types of bandage for treating venous leg ulcers. Health Technology Assessment 8(29), 1-134. [Free Full-text] Ilsley, K. (2001) Practice devises an effective strategy for venous leg ulceration. eGuidelines. www.eguidelines.co.uk [Accessed: 26/01/2004]. Jones, J.E. and Nelson, E.A. (2000) Skin grafting for venous leg ulcers (Cochrane Review). The Cochrane Library. Issue 2. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 21/02/2006]. [Free Full-text] Jull, A., Waters, J. and Arroll, B. (2002) Pentoxifylline for treatment of venous leg ulcers: a systematic review. Lancet 359(9317), 1550-1554. [NHS Athens Full-text] Kranke, P., Bennett, M., Roeckl-Wiedmann, I. and Debus, S. (2004) Hyperbaric oxygen therapy for chronic wounds (Cochrane Review). The Cochrane Library. Issue 1. Chichester, UK: Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 06/06/2007]. [Free Full-text] London, N.J.M. and Donnelly, R. (2000) ABC of arterial and venous disease: ulcerated lower limb. British Medical Journal 320(7249), 1589-1591. [Free Full-text] Mani, R., Vowden, K. and Nelson, E.A. (2001) Intermittent pneumatic compression for treating venous leg ulcers (Cochrane Review). The Cochrane Library. Issue 4. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 21/02/2006]. [Free Full-text] McNulty, C. (2004) Personal communication. Head, HPA Primary Care Unit, Health Protection Agency: Head, HPA Primary Care Unit. Moffatt, C.J., McCullagh, L., O'Connor, T. et al. (2003) Randomized trial of four-layer and twolayer bandage systems in the management of chronic venous ulceration. Wound Repair & Regeneration 11(3), 166-171. National Prescribing Centre (1999) Modern wound management dressings. Prescribing Nurse Bulletin 1(2), 5-8. Nelson, E.A., Bell-Syer, S. and Cullum, N.A. (2000) Compression for preventing recurrence of venous ulcers (Cochrane Review). The Cochrane Library. Issue 4. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 21/02/2006]. [Free Full-text] NHS CRD (1997) Compression therapy for venous leg ulcers. Effective Health Care 3(4), 1-12. O'Meara, S. and Ovington, L. (2002) Antibiotics and antiseptics for venous leg ulcers (Protocol for a Cochrane Review). The Cochrane Library. Issue 2. Chichester, UK: John Wiley & Sons, Ltd. www.thecochranelibrary.com [Accessed: 21/02/2006]. [Free Full-text] O'Meara, S., Cullum, N., Majid, M. and Sheldon, T. (2000) Systematic reviews of wound care management: (3) antimicrobial agents for chronic wounds; (4) diabetic foot ulceration. Executive summary. Health Technology Assessment 4(21), 1-4. [Free Full-text] Persoon, A., Heinen, M.M., van der Vleuten, C.J. et al. (2004) Leg ulcers: a review of their impact on daily life. Journal of Clinical Nursing 13(3), 341-354.

This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review. Please visit www.cks.library.nhs.uk to find the latest version.

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Royal College of Nursing (1998) The management of patients with venous leg ulcers. Recommendations for assessment, compression therapy, cleansing, debridement, dressing, contact sensitivity, training/education and quality assurance. Royal College of Nursing. www.rcn.org.uk [Accessed: 02/04/2004]. Royal College of Nursing (2000a) The management of patients with venous leg ulcers. Audit protocol. Royal College of Nursing. www.rcn.org.uk [Accessed: 07/02/2007]. [Free Full-text] Royal College of Nursing (2000b) The management of patients with venous leg ulcers. Implementation guide. Royal College of Nursing. www.rcn.org.uk [Accessed: 02/04/2004]. [Free Full-text] SIGN (1998) The care of patients with chronic leg ulcer. Scottish Intercollegiate Guidelines Network. www.sign.ac.uk [Accessed: 26/03/2004]. [Free Full-text] Simon, D.A., Dix, F.P. and McCollum, C.N. (2004) Management of venous leg ulcers. British Medical Journal 328(7452), 1358-1362. [Free Full-text] Thomas, S. (2004) Advice for community pharmacists on how to order and dispose of maggots. Pharmaceutical Journal 272(7287), 222-223. [Free Full-text] Wilkinson, E.A. and Hawke, C.I. (1998) Does oral zinc aid the healing of chronic leg ulcers? A systematic literature review. Archives of Dermatology 134(12), 1556-1560.

Patient information

Patient information from NHS Direct: · Leg ulcer Browse all NHS Direct patient information

Quick Reference Guide

· · Venous leg ulcer - not infected Venous leg ulcer - infected Quick Reference Guides are in Adobe PDF format. To view PDF files, You can download Adobe Reader which is freely available from the Adobe website at www.adobe.co.uk. Quick Reference Guides will open in a new browser window.

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