Latest research confirms that the fastest way to heal the commonest type of leg ulcer is “Early endovenous ablation of superficial venous reflux, in addition to compression therapy and wound dressings.”
This method reduces the time to healing of venous leg ulcers, increases ulcer-free time and is highly likely to be cost-effective (EVRA trial).”
What Does This Mean?
Lets’ cover what a leg ulcer is, what types of leg ulcer there are, what causes a venous leg ulcer and let’s discuss this latest research.
What Is A Leg Ulcer?
A leg ulcer describes a break in the skin, which allows air and bacteria to get into the leg. This is often caused by an injury, usually a minor one that cuts or grazes the skin.
In healthy people such an injury heals up quickly within a week or two. However, if the person has an underlying health problem, the skin does not heal and the area of breakdown can increase in size. This is what is meant by the term “chronic leg ulcer”.
All leg ulcers are a problem because they cause pain, disability and social isolation. In younger people, they can lead to time off work and sometimes loss of employment. All leg ulcers should be referred to a specialist team for assessment and treatment if they do not heal within 2 weeks.
What Does a Leg Ulcer Look Like?
A venous leg ulcer usually develops on the inner or outer side of the lower calf just above the ankle bone.
It causes pain, itch and swelling of the affected leg. It can become infected with a smelly discharge. The ulcer may cause time off work and require multiple hospital appointments.
The skin around the ulcer is often discoloured and thickened. Sometimes, varicose veins can be seen close to the ulcer.
What Causes a Leg Ulcer?
Venous Leg Ulcers can be caused by superficial veins which have faulty vein valves or by blockages in the deep veins. Faulty valves in the veins under the skin cause a condition called superficial venous reflux.
Deep Vein Thrombosis (DVT) affects the deep veins which are located in the muscles of the leg. DVT can damage the deep veins valves causing deep vein reflux or the DVT may narrow the deep veins causing deep vein obstruction.
The veins in your leg are blood vessels that carry the blood back from the foot towards your heart. The veins in your legs have one-way valves that make sure the blood flows up the leg and not back down towards the foot.
In some people, these valves are not very effective or they have been damaged by thrombosis (clots) in the veins. If the valves are faulty or damaged, blood can flow the wrong way down the veins, which results in a very high pressure in the veins when standing up. This abnormally high pressure in the veins damages the skin and leads to the ulcers.
As a result of the high back pressure in the veins, the capillaries in the skin circulation are deprived of nutrients and oxygen. Initially the skin damage looks like eczema and in the presence of varicose veins is called varicose eczema. In fact, varicose eczema is a warning sign that an ulcer is likely to develop.
Usually an ulcer breaks down in an area of varicose eczema and often, it follows a minor injury, such as a knock from a shopping trolley.
Research on the Best Treatment for Venous Leg Ulcers
In the short term, a venous leg ulcer should be managed by a specialist team experienced in cleaning and dressing the ulcer and in this way, the ulcer can be healed by using compression, such as bandages or stockings. This specialist team may be attached to a GP surgery. Most GP surgeries have a “leg ulcer nurse” supported by healthcare assistants.
In the longer term, the underlying vein problem should be identified by a Duplex Ultrasound Scan and if superficial venous reflux is found, it should be treated.
Vein treatments for venous leg ulcers caused by superficial venous reflux can nowadays be carried out very safely under local anaesthetic as a walk in, walk out non-invasive procedure and the age of the person with a leg ulcer is no longer a barrier to effective treatment. Once an ulcer is healed and the underlying vein problem is addressed, under the guidance of a healthcare professional and provided there are no other health issues such arterial disease or diabetes, the risk of the ulcer returning can be reduced by wearing good quality medical-grade compression hosiery.
How long will it take the ulcer to heal?
It has usually taken many years for the venous disease to cause the ulcers, so it is not surprising that the ulcers may take a fairly long time to heal. Although most venous ulcers will heal in 3-4 months, a small proportion will take considerably longer. Research in the UK published in 2019 has shown that treating Superficial Venous Reflux speeds up the time taken to get ulcers healed.
The Latest Research on the Best Way to Heal Leg Ulcers
In total, 450 people agreed to take part in this study and were treated in 20 hospitals across England. Participants were randomly allocated to either early or delayed endovenous ablation and followed up for 12 months. The trial found that treating the veins early resulted in quicker ulcer healing than delaying treatment until the ulcer had healed. The trial also showed that participants had more time without an ulcer if the treatment was performed early rather than after ulcer healing. No safety issues with early intervention were identified. There is some evidence that quality of life was better in the early treatment group and that people in this group had less body pain. Treating ulcers early appears likely to be more cost-effective (i.e. a better use of NHS resources) than delayed treatment.
This research was published 2 years ago but unfortunately, a survey published 6 months ago suggests that the UK has significantly longer referral times, longer waiting times to secondary care and longer times to intervention than other countries. This is supported elsewhere where it is suggested that the UK is possibly undertreating patients with chronic venous disease. This may relate to relative constraints of the National Health Service compared to other privatised health care systems globally.
- Venous leg ulcers are common, accounting for an estimated 80% of all leg ulcers and affecting up to 2% of the adult population.
- The condition can be extremely distressing for patients, greatly affecting their quality of life.
- There is evidence of considerable variation between National Health Service trusts as to which patients qualify for referral or treatment of varicose veins and leg ulcers.
- The 2013 NICE clinical guideline CG168 for the diagnosis and management of varicose veins recommends that patients with current ulceration should be referred to a vascular service for assessment and treatment within two weeks and that a venous duplex is performed to confirm the presence of superficial or deep venous reflux.
- The guidelines state that the first line of treatment should be vein treatment and that compression alone should only be used if this is not possible.
- A randomised controlled trial showed that treating vein problems speeds up the healing of an active ulcer.
- Compression stockings and vein treatments reduce the risk of ulcers coming back