Nearly Circumferential Venous Ulcers

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71 y.o. female with nearly circumferential venous stasis ulcers present for multiple years that had received multiple different dressings. Dressings that have been tried include: Aquacel AG (but only a limited amount), calcium alginate AG, Hydrolock dressings, ABD pads, 0.25% acetic acid, peri wound protection-Desitin, 18 treatments of Ultramist, lymphedema pumps and multilayer compression (ABI normal). She initially had a large amount of green drainage/pseudomonas which has improved. Patient is diabetic, not very compliant with blood sugars/eating habits, has a hemoglobin of 7 and receiving iron infusions. Wounds continue to have an extra large amount of drainage with maceration and hyper granulation. Any recommendations are appreciated. Thank you!

Dec 29, 2022 by Sarah Hintz,

2 replies

Elaine Horibe Song
MD, PhD, MBA

Hi Sarah

Thanks for your message and for sharing this case. For challenging ulcers that are not improving, it'd be important to take a step back and reevaluate all areas and concerns for not healing. Dr Charash wrote a great post on a similar case (please refer to https://woundreference.com/app/post?id=794). Samantha Kuplicki, NP and Dr Robinson's insights on a challenging weeping VLU might be helpful as well (https://woundreference.com/app/post?id=208)

It'd be important to reassess risk factors for delayed healing, if there is adequate blood supply to the ulcers, the potential for the ulcers to heal (i.e. healability), and if the VLU is considered simple or complex. For details, please refer to the VLU Assessment Algorithm ( https://woundreference.com/files/1532.pdf ). For instance, a healable "complex" VLU (i.e. those that are likely to take longer to heal) is expected to be 100% healed within 18 weeks. At minimum: ~70% is expected to be healed with adequate standard treatment within 24 weeks. If this is not observed, patient and ulcers should be reassessed. Before consideration of adjuvant therapies, a thorough re-evaluation of the patient and wound should be performed to: 1) rule out other differential diagnoses or mixed etiologies, 2) ensure that compression has achieved edema control, 3) bio-burden and exudate are well managed, and 4) factors impeding healing are not present or under control. Given the information provided on this case, it seems there is opportunity to address several of these items. Here is a checklist that elaborates each step in detail: https://woundreference.com/app/topic?id=venous-ulcers-treatment%20and%20prevention#plan-reassessment
Other resources: VLU Management Algorithm (https://woundreference.com/app/topic?id=venous-ulcers-treatment%20and%20prevention#algorithm)
Hope this helps!

Dec 31, 2022

Elaine Horibe Song
MD, PhD, MBA

Also, just discussed with Cathy Milne - as this case is similar to the previous case submitted to Curbside Consult. Cathy added that it'd be essential to decongest the legs, so that the lymphedema pump can work. If a lymphedema therapist is available, a referral would be advisable.

Jan 3, 2023

* Information provided without clinical evaluation and is not intended as a replacement for in-person consultation with a medical professional. The information provided through Curbside Consult is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

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