L97
DESCRIPTION
A chronic relapsing disorder of the lower limbs. It has many causes and is often associated with lipodermatosclerosis (bound-down, fibrosed skin) and eczema. It is mainly associated with vascular, predominantly venous, insufficiency and immobility. It is also associated with neuropathy and, occasionally, with infections, neoplasia, trauma, or other rare conditions.
GENERAL MEASURES
The aim of management should be to:
- Treat underlying conditions, e.g. heart failure, diabetes mellitus and venous stasis.
- Limit the extent of damage.
- Encourage rapid healing to minimise scarring and fibrosis.
- Prevent recurrences.
Avoid all topical irritants and allergens, e.g. lanolin, neomycin, bacitracin, parabens, fusidic acid, clioquinol, antihistamine creams, etc.
If the ulcer is oedema- or stasis-related, rest the leg in an elevated position.
In venous insufficiency, compression (bandages or stockings) is essential to achieve and maintain healing, provided the arterial supply is normal.
In patients with arterial insufficiency, avoid pressure elevation and compression bandages or stockings on bony prominences and the toes. Stress meticulous foot care and avoidance of minor trauma.
Walking and exercises are recommended.
Encourage patients with neuropathy not to walk barefoot, to check their shoes for foreign objects, examine their feet daily for trauma and to test bath water before bathing to prevent getting burnt.
Avoid excessive local heat.
Indications for surgical procedures include:
- slough removal
- arterial insufficiency
- surgery for varicose veins
- skin grafting
MEDICINE TREATMENT
Antibiotic therapy
Systemic antibiotics are seldom required for ulcers, and should be considered only if there is surrounding cellulitis. These infections are typically polymicrobial and broad-spectrum antibiotics are recommended.
- Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 7 days.
Local wound care
Topical cleansing
Use bland, non-toxic products to clean the ulcer and surrounding skin.
For clean uninfected wounds:
- Sodium chloride 0.9% or sterile water.
Dressed frequently with:
- Moistened dressing e.g. gauze with sodium chloride 0.9%.
For exudative, infected wounds:
- Povidone-iodine 5% cream, topical apply daily.