The influence of dressings on venous ulcer healing--a randomised trial

Effects of a Dietary Supplement Composed of Baicalin, Bromelain and Escin for Venous Chronic Insufficiency Treatment: Insights from a Retrospective Observational Study

Chronic venous insufficiency (CVI) represents a risk factor for cardiovascular events. The first-line treatment includes the use of compression stockings and lifestyle changes. Natural products, such as flavonoids, could be used to improve the effects of compression therapy due to their anti-inflammatory and anti-oxidant properties. This study aims to evaluate the effects of a dietary supplement containing baicalin, bromeline and escin in CVI patients. A retrospective cohort study was performed by using the medical records of CVI affected outpatients. Patients treated with the dietary supplement were defined as "users". A modified Venous Clinical Severity Score (VCSS) was calculated, including pain, inflammation, vessels induration and skin pigmentation. All clinical variables were evaluated at baseline (T0), after 30 (T1) and 90(T2) days in "users" and "non-users". Out of 62 patients, 30 (48.4%) were "users". No difference was observed between groups at baseline. A lower VCSS value was recorded in "users" than that observed in "non-users" at T2 (7.0 (4.0-9.0) vs. 9.0 (5.0-10.0); p = 0.025). Vessels' induration and pain significantly reduced in 53.3% and 43.3% of "users" and in 18.8% and 9.4% of "non-users". Only "users" (33.3%) showed a reduction of the inflammatory signs as well as a decrease in malleolar circumference, from 29.0 (26.5-30.0) to 27.5 (26.0-28.5) (p < 000.1). A reduction of C-reactive Protein levels was found in "users" compared to "non-users" at T2 (1.0 (0.9-1.2) vs. 1.3 (1.0-1.5); p = 0.006). These findings suggest that implementation of a dietary supplement could improve the clinical outcomes of CVI patients.

Randomized, double-blind clinical trial comparing the healing of stasis ulcers in lower limbs with standard hydrocolloid gel dressings and with dressings with Syzygium cumini extract

Objective

To evaluate the healing of venous ulcers in the lower limbs (VLU) using dressings with hydrocolloid gel associated with Syzygium cumini extract (SHG) compared to standard hydrocolloid gel dressings (HG).

Method

This prospective, double-blind, randomized trial recruited 90 patients with VLU divided into: dressings with SHG ( n = 44) and dressings with HG ( n = 46). Primary endpoint was healing in the 14th visit. Secondary endpoints were healing rate, complete healing during follow-up, and improvement in the pain scale and in quality of life.

Results

There were no significant between-group differences in healing ( p = 0.15). The wound area made healing difficult ( p = 0.008). Age, body mass index, and wound time demonstrated a tendency to worsen the healing. Positive culture for Pseudomonas aeruginosa resulted in 88% reduction in the healing risk ( p < 0.0001).

Conclusion

There was no difference between the dressings evaluated. The presence of Pseudomonas aeruginosa significantly impaired wound healing.

Zinc-nutrient element based alloys for absorbable wound closure devices fabrication: Current status, challenges, and future prospects

The need for the development of load-bearing, absorbable wound closure devices is driving the research for novel materials that possess both good biodegradability and superior mechanical characteristics. Biodegradable metals (BMs), namely: magnesium (Mg), zinc (Zn) and iron (Fe), which are currently being investigated for absorbable vascular stent and orthopaedic implant applications, are slowly gaining research interest for the fabrication of wound closure devices. The current review presents an overview of the traditional and novel BM-based intracutaneous and transcutaneous wound closure devices, and identifies Zn as a promising substitute for the traditional materials used in the fabrication of absorbable load-bearing sutures, internal staples, and subcuticular staples. In order to further strengthen Zn to be used in highly stressed situations, nutrient elements (NEs), including calcium (Ca), Mg, Fe, and copper (Cu), are identified as promising alloying elements for the strengthening of Zn-based wound closure device material that simultaneously provide potential therapeutic benefit to the wound healing process during implant biodegradation process. The influence of NEs on the fundamental characteristics of biodegradable Zn are reviewed and critically assessed with regard to the mechanical properties and biodegradability requirements of different wound closure devices. The opportunities and challenges in the development of Zn-based wound closure device materials are presented to inspire future research on this rapidly growing field.

Varicose Veins and Chronic Venous Disease

Chronic venous disease is a worldwide problem associated with significant morbidity and is expected to increase in prevalence as the current population ages. This is a comprehensive review of the anatomy, pathophysiology, genomics, clinical classification, and treatment modalities of chronic venous disease.

Biomarker directed chronic wound therapy - A new treatment paradigm

AIM

To develop a treatment paradigm for chronic leg ulcers that incorporates new biomarkers of wound healing with currently available therapies.

METHODS

Recently published data on GM-CSF and MMP-13 as biomarkers of venous leg ulcer (VLU) healing status with accuracies of 92% and 78% respectively, was reviewed along with the wound bed preparation (WBP) theoretical framework for treatment of chronic wounds. The broad categories of wound treatments that align with the WBP concepts were identified. These were then considered in a hierarchical order that initially improves the wound bed and subsequently incorporates more complex advanced wound therapies. Identification of the non-healing status of the wound is the driver to advance through the different treatments.

RESULTS

A point of care test of wound healing status is the key to the systematic use of currently available therapies for chronic leg ulcers in a timely fashion. The different therapies address - debridement, moisture control, bacterial contamination, protease inhibition, formation of granulation tissue, application of growth factors, application of matrix constructs, and application of cellular components. Progression through this hierarchical order of therapies is directed by the leg ulcer remaining in a non-healing state with the previous therapies having been implemented.

CONCLUSION

Combining a validated point of care test of wound healing with a systematic approach to wound therapies, has the potential to create a new paradigm of chronic leg ulcer treatment - biomarker directed wound therapy.

Dressings and topical agents for treating venous leg ulcers

BACKGROUND

Venous leg ulcers are open skin wounds on the lower leg which can be slow to heal, and are both painful and costly. The point prevalence of open venous leg ulcers in the UK is about 3 cases per 10,000 people, and many people experience recurrent episodes of prolonged ulceration. First-line treatment for venous leg ulcers is compression therapy, but a wide range of dressings and topical treatments are also used. This diversity of treatments makes evidence-based decision-making challenging, and a clear and current overview of all the evidence is required. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents.

OBJECTIVES

To assess the effects of (1) dressings and (2) topical agents for healing venous leg ulcers in any care setting and to rank treatments in order of effectiveness, with assessment of uncertainty and evidence quality.

SEARCH METHODS

In March 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We updated this search in March 2018; as a result several studies are awaiting classification.

SELECTION CRITERIA

We included published or unpublished randomised controlled trials (RCTs) that enrolled adults with venous leg ulcers and compared the effects of at least one of the following interventions with any other intervention in the treatment of venous leg ulcers: any dressing, or any topical agent applied directly to an open venous leg ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factors and other biological agents, larval therapy and treatments such as laser, heat or ultrasound. Studies were required to report complete wound healing to be eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We conducted this NMA using frequentist meta-regression methods for the efficacy outcome; the probability of complete healing. We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals (CIs) for individual treatments focusing on comparisons with widely used dressing classes, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole.

MAIN RESULTS

We included 78 RCTs (7014 participants) in this review. Of these, 59 studies (5156 participants, 25 different interventions) were included in the NMA; resulting in 40 direct contrasts which informed 300 mixed-treatment contrasts.The evidence for the network as a whole was of low certainty. This judgement was based on the sparsity of the network leading to imprecision and the general high risk of bias in the included studies. Sensitivity analyses also demonstrated instability in key aspects of the network and results are reported for the extended sensitivity analysis. Evidence for individual contrasts was mainly judged to be low or very low certainty.The uncertainty was perpetuated when the results were considered by ranking the treatments in terms of the probability that they were the most effective for ulcer healing, with many treatments having similar, low, probabilities of being the best treatment. The two most highly-ranked treatments both had more than 50% probability of being the best (sucralfate and silver dressings). However, the data for sucralfate was from one small study, which means that this finding should be interpreted with caution. When exploring the data for silver and sucralfate compared with widely-used dressing classes, there was some evidence that silver dressings may increase the probability of venous leg ulcer healing, compared with nonadherent dressings: RR 2.43, 95% CI 1.58 to 3.74 (moderate-certainty evidence in the context of a low-certainty network). For all other combinations of these five interventions it was unclear whether the intervention increased the probability of healing; in each case this was low- or very low-certainty evidence as a consequence of one or more of imprecision, risk of bias and inconsistency.

AUTHORS' CONCLUSIONS

More research is needed to determine whether particular dressings or topical agents improve the probability of healing of venous leg ulcers. However, the NMA is uninformative regarding which interventions might best be included in a large trial, largely because of the low certainty of the whole network and of individual comparisons.The results of this NMA focus exclusively on complete healing; whilst this is of key importance to people living with venous leg ulcers, clinicians may wish to take into account other patient-important outcomes and factors such as patient preference and cost.

Combined Topical Growth Factor and Protease Inhibitor in Chronic Wound Healing: Protocol for a Randomized Controlled Proof-of-Concept Study

Background

Leg ulcers due to venous disease are chronic wounds that can take 6 or more months to heal. Growth factors have been used to try and improve this healing; however, many such studies have failed, and that is thought to be due to enzymes in the wound that degrade the growth factors and prevent them from working.

Objective

This is a proof-of-concept study that will evaluate the treatment of chronic leg ulcers with topically applied growth factors that are combined with a therapy to prevent their inactivation in the wound. This combined therapy has the potential to speed up the healing of these wounds and thereby improve the quality of life of patients and reduce the costs to the health system.

Methods

This will be a double-blind, placebo-controlled, randomized controlled proof-of-concept study comparing growth factor with protease inhibitor wound dressings to growth factors with standard wound dressings.

Results

The project was funded by the Canadian Institutes for Health Research and enrollment is expected to be initiated in 2018. It is expected that results will be available in 2021.

Conclusions

It is expected that the results of this trial will inform as to whether modifying the wound environment through the use of protease inhibitors increases the effectiveness of topically applied growth factors in the healing of chronic wounds.

Trial Registration

ClinicalTrials.gov NCT02845466; https://clinicaltrials.gov/ct2/show/NCT02845466 (Archived by WebCite at http://www.webcitation.org/6yOPhSBUA)

Die chronische venöse Insuffizienz - Eine Zusammenfassung der Pathophysiologie, Diagnostik und Therapie

Die chronische Venenerkrankung ist eine weit verbreitete Krankheit, die in späteren Stadien mit einer Vielzahl an Symptomen, aber auch Komplikationen wie dem Ulcus cruris, einhergeht. Dies wiederum hat weitreichende Auswirkungen auf die Lebensqualität der Patienten wie auch auf das Gesundheitssystem. Für die Diagnostik der chronischen Venenerkrankungen steht eine Auswahl an Verfahren zur Verfügung, wobei sich die farbkodierte Duplexsonographie als Goldstandard etabliert hat. Im Bereich der Therapie kam es in den letzten Jahrzehnten zu großen Fortschritten, sodass heute auch Alternativen zum klassischen Stripping durch die endoluminalen Verfahren zur Verfügung stehen. Die Wahl der Therapieoption ist jedoch weiterhin stark abhängig von mehreren Faktoren, unter anderem von den anatomischen Gegebenheiten und dem Krankheitsstadium. Im folgenden Artikel werden die Anatomie und Pathophysiologie, sowie die aktuellen Standards der Diagnostik und Therapie zusammengefasst.

Chronic venous insufficiency - a review of pathophysiology, diagnosis, and treatment

Chronic venous disease is a common disorder associated with a variety of symptoms in later disease stages but also with complications such as venous leg ulcer. This, in turn, has substantial socioeconomic effects and significantly impacts patients' quality of life. While there are a number of diagnostic procedures available, color-flow duplex ultrasound has become the gold standard. As regards therapeutic options, major advances have been made in recent decades. Today, there are alternatives to saphenofemoral ligation and stripping of the great saphenous vein, including endovenous thermal ablation techniques. However, treatment selection continues to depend on many factors such as individual anatomical circumstances and disease stage. The following article provides an overview of the anatomy and pathophysiology as well as current diagnostic and therapeutic standards.

The Influence of Minimal-Stretch and Elasticated Bandages on Calf Muscle Pump Function in Patients with Chronic Venous Disease

Objective:

To evaluate the influence of minimal-stretch and elasticated bandages on calf muscle pump function in patients with chronic venous disease.

Design:

An open, randomised, crossover study.

Setting:

University Department of Surgery, Fremantle Hospital, Perth, Australia.

Subjects:

Twenty patients with chronic venous disease and recently healed chronic venous ulcers.

Method:

Five different bandaging regimens were applied on each patient, and calf muscle pump function was assessed by using air plethysmography.

Results:

There was no significant difference in the venous filling index (VFI) and ejection fraction (EF) between the five different bandage regimens, and also no significant difference in four of the five bandage regimens over a 7-day period ( p>0.05). However, the VFI was significantly reduced and the EF was not significantly altered after the application of both elasticated and minimal-stretch bandages ( p<0.05, = p>0.05 respectively).

Conclusion:

All the bandage regimens used in this study have a similar influence on calf muscle pump function, and may therefore have a similar effect on the healing of chronic venous ulcers.

Contemporary management of acute and chronic deep venous thrombosis

INTRODUCTION

This review aims to provide an update on the management of deep vein thrombosis (DVT).

SOURCES OF DATA

A systematic search of PubMed, Google Scholar and Cochrane databases was carried out.

AREAS OF AGREEMENT

Direct oral anticoagulants (DOACs) are as effective and easier to use than vitamin K antagonists for the treatment of DVT. Catheter-directed thrombolysis can reduce post thrombotic syndrome in patients with iliofemoral DVT. Compression bandaging can help heal a venous ulcer.

AREAS OF CONTROVERSY

Compression hosiery to prevent post thrombotic syndrome. Long-term evidence to show clinical benefit of using endovenous therapies to restore deep vein patency.

GROWING POINTS

Developing imaging methods to identify patients who would benefit from venous thrombolysis. The evolution of dedicated venous stents.

AREAS TIMELY FOR DEVELOPING RESEARCH

Understanding the mechanisms that lead to stent occlusion and investigation into the appropriate treatments that could prevent in-stent thrombosis is required.

Risk factors for delayed healing in venous leg ulcers: a review of the literature

BACKGROUND

Chronic leg ulcers, remaining unhealed after 4-6 weeks, affect 1-3% of the population, with treatment costly and health service resource intensive. Venous disease contributes to approximately 70% of all chronic leg ulcers and these ulcers are often associated with pain, reduced mobility and a decreased quality of life. Despite evidence-based care, 30% of these ulcers are unlikely to heal within a 24-week period and therefore the recognition and identification of risk factors for delayed healing of venous leg ulcers would be beneficial.

AIM

To review the available evidence on risk factors for delayed healing of venous leg ulcers.

METHODS

A review of the literature in regard to risk factors for delayed healing in venous leg ulcers was conducted from January 2000 to December 2013. Evidence was sourced through searches of relevant databases and websites for resources addressing risk factors for delayed healing in venous leg ulcers specifically.

RESULTS

Twenty-seven studies, of mostly low-level evidence (Level III and IV), identified risk factors associated with delayed healing. Risk factors that were consistently identified included: larger ulcer area, longer ulcer duration, a previous history of ulceration, venous abnormalities and lack of high compression. Additional potential predictors with inconsistent or varying evidence to support their influence on delayed healing of venous leg ulcers included: decreased mobility and/or ankle range of movement, poor nutrition and increased age.

DISCUSSION

Findings from this review indicate that a number of physiological risk factors are associated with delayed healing in venous leg ulcers and that social and/or psychological risk factors should also be considered and examined further.

CONCLUSION

The findings from this review can assist health professionals to identify prognostic indicators or risk factors significantly associated with delayed healing in venous leg ulcers. This will facilitate realistic outcome planning and inform implementation of appropriate early strategies to promote healing.

Alginate dressings for venous leg ulcers

BACKGROUND

Venous leg ulcers are a common and recurring type of chronic, complex wound associated with considerable cost to patients and healthcare providers. To aid healing, primary wound contact dressings are usually applied to ulcers beneath compression devices. Alginate dressings are used frequently and there is a variety of alginate products on the market, however, the evidence base to guide dressing choice is sparse. 

OBJECTIVES

To determine the effects of alginate dressings compared with alternative dressings, non-dressing treatments or no dressing, with or without concurrent compression therapy, on the healing of venous leg ulcers.

SEARCH METHODS

For this first update, in March 2015, we searched the following databases: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any type of alginate dressing in the treatment of venous ulcers were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data extraction and risk of bias assessment. Meta-analysis was undertaken when deemed feasible and appropriate.

MAIN RESULTS

Five RCTs (295 participants) were included in this review. All were identified during the original review. The overall risk of bias was high for two RCTs and unclear for three. One RCT compared different proprietary alginate dressings (20 participants), three compared alginate and hydrocolloid dressings (215 participants), and one compared alginate and plain non-adherent dressings (60 participants). Follow-up periods were six weeks in three RCTs and 12 weeks in two. No statistically significant between-group differences were detected for any comparison, for any healing outcome. Meta-analysis was feasible for one comparison (alginate and hydrocolloid dressings), with data from two RCTs (84 participants) pooled for complete healing at six weeks: risk ratio 0.42 (95% confidence interval 0.14 to 1.21). Adverse event profiles were generally similar between groups (not assessed for alginate versus plain non-adherent dressings).

AUTHORS' CONCLUSIONS

The current evidence base does not suggest that alginate dressings are more or less effective in the healing of venous leg ulcers than hydrocolloid or plain non-adherent dressings, and there is no evidence to indicate a difference between different proprietary alginate dressings. However, the RCTs in this area are considered to be of low or unclear methodological quality. Further, good quality evidence is required from well designed and rigorously conducted RCTs that employ - and clearly report on - methods to minimise bias, prior to any definitive conclusions being made regarding the efficacy of alginate dressings in the management of venous leg ulcers.

Chronic venous leg ulcers: is topical zinc the answer? A review of the literature

PURPOSE

To enhance the learner's competence with knowledge of research data on topical zinc for treatment of chronic leg ulcers.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES

After participating in this educational activity, the participant should be better able to:

ABSTRACT

Venous leg ulcers (VLUs) are chronic leg wounds that can have a debilitating effect on the physical and psychological health of patients. Older patients, who are a vulnerable group, suffer from VLUs more frequently, and the prevalence of these ulcers increases as the population ages. Venous leg ulcers also pose a serious cost to the healthcare industry. Zinc, in the form of topical creams and lotions, has been used in wound care for more than 3,000 years and is now contained in a variety of wound care products that are used in the treatment of chronic VLUs.

OBJECTIVE

The aim of this review was to examine the current empirical evidence to assess if topical zinc-based wound products are effective in promoting the healing of VLUs.

METHODS

Following a systematic search and review of the literature, based on selected keywords, 11 studies were identified as being relevant, and data were extracted using content analysis.

RESULTS

The results show that there is currently very poor-quality evidence to suggest that topical zinc-based wound products are effective in healing VLUs, either in conjunction with compression therapy, as compression bandages themselves, or as a topical skin protectant. Some of the studies were sponsored by industry, which challenges the validity and reliability of their results.

CONCLUSIONS

It is apparent that not only was much of the literature conducted on a small scale, it is also outdated and methodologically inconsistent. There is scant high-quality evidence to suggest that topical zinc-based wound products are effective in promoting the healing of VLUs. New studies are urgently needed that are larger, scientifically rigorous, and without bias from industry. This will enable clinicians to implement evidenced-based practice and choose the most appropriate wound management product to improve patient care and reduce the costs of healthcare.

Alginate dressings for venous leg ulcers

BACKGROUND

Venous leg ulcers are a common and recurring type of chronic, complex wound associated with considerable cost to patients and healthcare providers. To aid healing, primary wound contact dressings are usually applied to ulcers beneath compression devices. Alginate dressings are used frequently and there is a variety of alginate products on the market, however, the evidence base to guide dressing choice is sparse.

OBJECTIVES

To determine the effects of alginate dressings compared with alternative dressings, non-dressing treatments or no dressing, with or without concurrent compression therapy, on the healing of venous leg ulcers.

SEARCH METHODS

We searched The Cochrane Wounds Group Specialised Register (searched 30 November 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11); The NHS Economic Evaluation Database (NHS EED) (The Cochrane Library 2012, Issue 5); Ovid MEDLINE (1946 to November Week 2 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations November 29, 2012); Ovid EMBASE (1980 to 2011 Week 11); and EBSCO CINAHL (1982 to 23 November 2012). There were no restrictions based on language or date of publication.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any type of alginate dressing in the treatment of venous ulcers were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data extraction and risk of bias assessment. Meta-analysis was undertaken when deemed feasible and appropriate.

MAIN RESULTS

Five RCTs (295 participants) were included in this review. Overall risk of bias was high for two RCTs and unclear for three. One RCT compared different proprietary alginate dressings (20 participants), three compared alginate and hydrocolloid dressings (215 participants), and one compared alginate and plain non-adherent dressings (60 participants). Follow-up periods were six weeks in three RCTs and 12 weeks in two. No statistically significant between-group differences were detected for any comparison, for any healing outcome. Meta-analysis was feasible for one comparison (alginate and hydrocolloid dressings), with data from two RCTs (84 participants) pooled for complete healing at six weeks: risk ratio 0.42 (95% confidence interval 0.14 to 1.21). Adverse event profiles were generally similar between groups (not assessed for alginate versus plain non-adherent dressings).

AUTHORS' CONCLUSIONS

The current evidence base does not suggest that alginate dressings are more or less effective in the healing of venous leg ulcers than hydrocolloid or plain non-adherent dressings, and there is no evidence to indicate a difference between different proprietary alginate dressings. However, the RCTs in this area are considered to be of low or unclear methodological quality. Further, good quality evidence is required from well designed and rigorously conducted RCTs that employ - and clearly report on - methods to minimise bias, prior to any definitive conclusions being made regarding the efficacy of alginate dressings in the management of venous leg ulcers.

The effectiveness of a four-layer compression bandage system in comparison with Class 3 compression hosiery on healing and quality of life in patients with venous leg ulcers: a randomised controlled trial

An increasing number of compression systems available for treatment of venous leg ulcers and limited evidence on the relative effectiveness of these systems are available. The purpose of this study was to conduct a randomised controlled trial to compare the effectiveness of a four-layer compression bandage system and Class 3 compression hosiery on healing and quality of life (QL) in patients with venous leg ulcers. Data were collected from 103 participants on demographics, health, ulcer status, treatments, pain, depression and QL for 24 weeks. After 24 weeks, 86% of the four-layer bandage group and 77% of the hosiery group were healed (P = 0·24). Median time to healing for the bandage group was 10 weeks, in comparison with 14 weeks for the hosiery group (P = 0·018). The Cox proportional hazards regression found participants in the four-layer system were 2·1 times (95% CI 1·2-3·5) more likely to heal than those in hosiery, while longer ulcer duration, larger ulcer area and higher depression scores significantly delayed healing. No differences between groups were found in QL or pain measures. Findings indicate that these systems were equally effective in healing patients by 24 weeks; however, a four-layer system may produce a more rapid response.

Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers

OBJECTIVE

To compare the proportion and rate of healing, pain, and quality of life of low-strength medical compression stockings (MCS) with traditional bandages applied for the treatment of recalcitrant venous leg ulcers.

METHODS

A single-center, randomized, open-label study was performed with consecutive patients. Sigvaris prototype MCS providing 15 mm Hg-25 mm Hg at the ankle were compared with multi-layer short-stretch bandages. In both groups, pads were placed above incompetent perforating veins in the ulcer area. The initial static pressure between the dressing-covered ulcer and the pad was 29 mm Hg and 49 mm Hg with MCS and bandages, respectively. Dynamic pressure measurements showed no difference. Compression was maintained day and night and changed every week. The primary endpoint was healing within 90 days. Secondary endpoints were healing within 180 days, time to healing, pain (weekly Likert scales), and monthly quality of life (ChronIc Venous Insufficiency Quality of Life [CIVIQ] questionnaire).

RESULTS

Of 74 patients screened, 60 fulfilled the selection criteria and 55 completed the study; 28 in the MCS and 27 in the bandage group. Ulcers were recurrent (48%), long lasting (mean, 27 months), and large (mean, 13 cm2). All but one patient had deep venous reflux and/or incompetent perforating veins in addition to trunk varices. Characteristics of patients and ulcers were evenly distributed (exception: more edema in the MCS group; P = .019). Healing within 90 days was observed in 36% with MCS and in 48% with bandages (P = .350). Healing within 180 days was documented in 50% with MCS and in 67% with bandages (P = .210). Time to healing was identical. Pain scored 44 and 46 initially (on a scale in which 100 referred to maximum and 0 to no pain) and decreased within the first week to 20 and 28 in the MCS and bandage groups, respectively (P < .001 vs .010). Quality of life showed no difference between the treatment groups. In both groups, pain at 90 days had decreased by half, independent of completion of healing. Physical, social, and psychic impairment improved significantly in patients with healed ulcers only.

CONCLUSION

Our study illustrates the difficulty of bringing large and long-standing venous ulcers to heal. The effect of compression with MCS was not different from that of compression with bandages. Both treatments alleviated pain promptly. Quality of life was improved only in patients whose ulcers had healed.

Systematic review of topic treatment for venous ulcers

Venous ulcer patients can experience this situation for several years without achieving healing if treatment is inadequate. Evidence-based professional practice generates effective results for patients and services. This research aimed to carry out a systematic review to assess the most effective method to improve venous return and the best topic treatment for these ulcers. Studies were collected in eight databases, using the following descriptors: leg ulcer, venous ulcer and similar terms. The sample consisted of 33 primary studies and two Meta-analyses. A wide range of treatments was identified, grouped in compression therapy (54.3%) and topical treatment (45.7%). It was evidenced that compression therapy increases ulcer healing rates and should be used in patients with intact arteries. There is no consensus about the best topical treatment, although different options should be associated with compression therapy.

Zinc in wound healing: theoretical, experimental, and clinical aspects

Zinc is an essential trace element in the human body and its importance in health and disease is appreciated. It serves as a cofactor in numerous transcription factors and enzyme systems including zinc-dependent matrix metalloproteinases that augment autodebridement and keratinocyte migration during wound repair. Zinc confers resistance to epithelial apoptosis through cytoprotection against reactive oxygen species and bacterial toxins possibly through antioxidant activity of the cysteine-rich metallothioneins. Zinc deficiency of hereditary or dietary cause can lead to pathological changes and delayed wound healing. Oral zinc supplementation may be beneficial in treating zinc-deficient leg ulcer patients, but its therapeutic place in surgical patients needs further clarification. Topical administration of zinc appears to be superior to oral therapy due to its action in reducing superinfections and necrotic material via enhanced local defense systems and collagenolytic activity, and the sustained release of zinc ions that stimulates epithelialization of wounds in normozincemic individuals. Zinc oxide in paste bandages (Unna boot) protects and soothes inflamed peri-ulcer skin. Zinc is transported through the skin from these formulations, although the systemic effects seem insignificant. We present here the first comprehensive account of zinc in wound management in relation to current concepts of wound bed preparation and the wound-healing cascade. This review article suggests that topical zinc therapy is underappreciated even though clinical evidence emphasizes its importance in autodebridement, anti-infective action, and promotion of epithelialization.

A systematic review of randomized controlled trials of wound dressings for chronic venous ulcer

OBJECTIVE

To determine whether more "modern" complex wound dressings further improve the healing of venous ulcers over that with simple wound dressings, we conducted a systematic review of randomized controlled trials (RCTs) of wound dressing trials that were published from October 1, 1997, through September 1, 2005.

METHODS

We searched MEDLINE, CINAHL, and the Cochrane Controlled Trials Registry Database to identify RCTs. Criteria for ultimate selection included treatment with compression and an objective outcome describing the proportion of wounds healed. Twenty RCTs were identified that satisfied these criteria and were classified into three wound dressing classes: semiocclusive/occlusive group (n = 8), growth factor group (n = 7), and human skin equivalent group (n = 5).

RESULTS

Assessment of study design quality for the 20 RCTs showed a low percentage (<49%) of RCTs that incorporated at least 3 of 7 indicators of trial quality, but it seemed better in the 5 RCTs that showed significance for ulcer healing; 4 of the studies used at least 6 of the 7 characteristics of adequate study design. Five (25%) of the 20 RCTs had a statistically significantly improved proportion of ulcers healed in the experimental dressing group over control values: zinc oxide paste bandage (79% vs 56%) and Tegasorb (59% vs 15%) in the semiocclusive/occlusive group and perilesional injection of granulocyte-macrophage colony-stimulating factor (57% vs 19%) and porcine collagen derived from small-intestine submucosa (Oasis; 55% vs 34%) in the growth factor group. In the sole significant RCT from the human skin equivalent group, Apligraf (63%) was superior to Tegapore (48%). Four of these five studies also showed an improved time to complete healing by Kaplan-Meier estimate.

CONCLUSIONS

Certain wound dressings can improve both the proportion of ulcers healed and the time to healing over that achieved with adequate compression and a simple wound dressing. The selection of a specific dressing, however, will depend on the dressing characteristics for ease of application, patient comfort, wound drainage absorption, and expense.

Dressings for healing venous leg ulcers

BACKGROUND

Venous leg ulcers, sometimes called varicose or stasis ulcers, are a consequence of damage to the valves in the veins of the legs, leading to raised venous pressure. Venous ulcers are characterised by a cyclical pattern of healing and recurrence. The main treatment is the application of compression, either in the form of compression bandages or hosiery. Dressings are usually applied beneath the compression to aid healing, comfort and to control exudate. Wounds heal quicker in a moist environment and dressings are used to absorb excess fluid or retain fluid in an otherwise dry wound in order to achieve a 'moist wound environment'. There are a large number of dressing products and types available. It is unclear whether particular dressings aid healing of leg ulcers.

OBJECTIVES

To assess the effectiveness of wound dressings for the treatment of venous leg ulcers.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (April 2006) and CENTRAL (issue 1, 2006) and several other electronic databases (up to April 2005). Manufacturers of dressing products were contacted for unpublished studies.

SELECTION CRITERIA

Randomised controlled trials that evaluated dressings for the treatment of venous leg ulcers. There was no restriction in terms of source, date of publication or language. Ulcer healing was the primary endpoint.

DATA COLLECTION AND ANALYSIS

Data from eligible studies were extracted and summarised using a data extraction sheet by two authors independently.

MAIN RESULTS

42 randomised controlled studies were identified that met the inclusion criteria. The main dressing types that were evaluated were hydrocolloids (n = 23), foams (n = 6), alginates (n = 4), hydrogel dressings (n = 6) and a group of miscellaneous dressings (n = 3). In none of the comparisons was there evidence that any one dressing type was better than others in terms of number of ulcers healed. Current evidence does not suggest that hydrocolloids are more effective than simple low adherent dressings used beneath compression (9 trials; relative risk for healing with hydrocolloid 1.09 (95% CI 0.89 to 1.34)). For other comparisons there was insufficient evidence.

AUTHORS' CONCLUSIONS

The type of dressing applied beneath compression has not been shown to affect ulcer healing. For the majority of dressing types there was insufficient data to allow us to draw strong conclusions except for hydrocolloid compared with a low adherent dressing. The result of the meta-analysis indicate no significant difference in healing rates between hydrocolloid dressings and simple, low-adherent dressings when used beneath compression. Decisions regarding which dressing to apply should be based on local costs of dressings and practitioner or patient preferences.

Efficacy of modern dressings in the treatment of leg ulcers: A systematic review

Healing of leg ulcers constitutes a major clinical problem. Local methods for accelerating the healing process include modern wound dressings, but it is unclear what impact these dressings have on ulcer healing. This study examines the collective evidence on the effectiveness of modern dressings in the treatment of leg ulcers. To this end, a meta-analysis was conducted covering randomized clinical trials identified following a systematic review of the literature in different databases. Estimates of effect were calculated according to the fixed effects model. Thirty-one studies met the inclusion criteria (26 on ulcers of venous etiology, 5 on ulcers of mixed or poorly differentiated etiology). We found no study that exclusively addressed arterial ulcers. Although studies displayed considerable methodological limitations, analysis showed no significant differences in terms of the proportion of healed ulcers or reduction in wound size for both modern and conventional dressings. Similarly, no significant differences were observed between the different modern dressings compared in the studies. Thus, the current medical literature is poor in supporting the use of modern dressings to improve the healing rate of leg ulcers. There is insufficient evidence to determine whether the choice of any specific dressing type affects the healing course of these ulcers. Well-conducted trials are warranted to reliably address this question.

The release of zinc ions from and cytocompatibility of two zinc oxide dressings

OBJECTIVE

These in vitro studies examined the release of zinc ions from and the response of human dermal fibroblasts to two zinc oxide-medicated dressings: one with zinc oxide in an ointment base and one using polyvinylpyrrolidone (PVP), a hydrophilic polymer for the binding of zinc oxide particles.

METHOD

Zinc release from the dressings in buffered-saline (pH 7.4) was studied through a high-pore-density membrane (pore size, 0.40 microm) in a two-compartment model at 37 degrees C for three hours. Cytocompatibility of the dressings and 500 micromol/l of zinc ions was assessed using the MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyltetrazolium bromide) assay after exposure to monolayers of confluent normal human dermal fibroblasts to the dressing extracts for four hours.

RESULTS

The zinc release rate from PVP-bound zinc oxide was more than two-fold higher than from zinc oxide in the ointment. Extract of the zinc oxide ointment, containing 150 micromol/l solubilised zinc, elicited a cytotoxic reaction, while the zinc oxide-PVP extract, containing 410 micromol/l solubilised zinc, and 500 micromol/l zinc chloride were non-cytotoxic to the fibroblasts.

CONCLUSION

Zinc release in a simulated wound milieu appears to be inhibited when zinc oxide is incorporated in a lipophilic vehicle. It is hypothesised that the ointment vehicle induced cytotoxicity rather then the solubilised zinc oxide.

DECLARATION OF INTEREST

None.

Evaluation of Urgotol plus K-Four compression for venous leg ulcers

In this non-comparative clinical evaluation, 36 subjects with venous leg ulcers, 85% of which were indolent or deteriorating, were treated with Urgotul lipidocolloid wound dressing and the K-Four multilayer compression bandaging system for 12 weeks or to healing--whichever occurred first. Results show that Urgotul was an ideal dressing in combination with K-Four, being easy to apply (98.7%) and remove (98.1%), and largely pain-free (95.6%) and non-adherent (99.7%). In a patient group of "hard-to-heal" ulcers, 50% of the ulcers healed within the treatment period. Ulcers not healed after 12 weeks achieved almost 50% area reduction on average. The treatment combination proved safe, with only one of seven adverse events reported being probably related to the products used. This study supports the use of a combination of Urgotul dressing and K-Four compression to provide a "matched" treatment for venous leg ulcers.

Making sense of the venous leg ulcer debate: a literature review

Venous leg ulcers cause patients much distress. Treating them is expensive, with many hidden costs. As understanding of the causes and development of this condition improves, debate over the best treatments or treatment combinations is growing.

Randomized clinical trial of three-layer paste and four-layer bandages for venous leg ulcers

BACKGROUND

Both four-layer and three-layer paste bandages are widely used in the treatment of venous leg ulcers. The aim of this study was to compare the efficacy of these two bandaging regimens.

METHODS

The study was a prospective, randomized, open comparison of a consecutive cohort of 133 patients with venous ulcers. Participants were stratified by ulcer size into one of three groups and were randomized within each group to receive either three-layer paste or four-layer bandages. All patients were followed for 1 year. The time taken to complete ulcer healing was the primary endpoint. The time taken to apply the bandages, comfort, tolerability and cost were also assessed. Analysis was performed on the basis of intention to treat.

RESULTS

Ulcers healed completely in 51 (80 per cent) of 64 patients treated with three-layer paste bandages compared with 45 (65 per cent) of 69 patients treated with the four-layer regimen (P = 0.031). This difference developed only after 20 weeks of treatment. The median times to complete healing were 12 weeks for three-layer and 16 weeks for four-layer treatment (P = 0.040). Results of venous function tests, including half-refilling times, were similar in the two groups.

CONCLUSION

Three-layer paste bandages were significantly more effective at healing venous ulcers than the four-layer regimen in this study.

Hydrocolloids in wound management: pros and cons

Hydrocolloids are interactive dressings which are well established in wound management. Because of their sophisticated composition, they can be used to manage a variety of wound types, from clean and granulating to sloughy and necrotic. While they may be more expensive per item than many other modern dressings, if used correctly they can be cost-effective, as they have a longer wear time. Hydrocolloid formulations appear to be changing and improving with ongoing research by manufacturers, but a significant limitation appears to be sensitivity reactions. Dressings that would benefit from improvement are those containing gelatin, and those containing colophony within the adhesive matrix. These known sensitizers are largely unpublicised, but can produce serious side effects in some individuals.

Clinical trials in wound care. II: Achieving statistical significance

Clinical trials must be well designed in order to produce statistically and clinically significant results. This article describes the randomisation techniques that can prevent bias, the importance of sample size and the concept of power analysis.

Randomized clinical trial comparing the efficacy of two bandaging regimens in the treatment of venous leg ulcers

BACKGROUND

Many venous ulcers are healed by the application of external compression. It has been suggested that bandages capable of producing greater compression enhance healing. The aim of this study was to compare the time to total healing of venous ulcers in two groups of patients treated with different compression regimens in a randomized prospective trial.

METHODS

A total of 112 patients was studied and all were treated with a zinc-impregnated paste bandage applied directly to the ulcer. Fifty-seven patients had the paste covered by Tensopress and 55 by Elastocrepe bandages. Both groups had a tubular bandage applied over the top to retain the bandage in place. All ulcers were stratified and randomized within one of three size groups. The 'venous' aetiology of the ulcer was confirmed on completion by calf pump function tests.

RESULTS

By 26 weeks, 58 per cent of the patients treated with Tensopress and 62 per cent of those treated with Elastocrepe bandages were healed. The median healing times were 9 and 9.5 weeks respectively. Similar numbers of patients were excluded or withdrawn from both groups. Large ulcers healed significantly more slowly than small ulcers.

CONCLUSION

There was no significant improvement in venous ulcer healing using higher compression elastic bandages.

Randomised double-blind placebo controlled trial of topical autologous platelet lysate in venous ulcer healing

OBJECTIVES

to assess the effect of topical autologous platelet lysate on the healing of chronic venous ulcers.

DESIGN

a randomised placebo controlled double-blind trial.

MATERIALS

all patients had blood taken for preparation of autologous platelet lysate.

METHODS

patients with proven chronic venous ulceration were randomised to the trial. Autologous platelet lysate or placebo buffer solution were applied twice per week for up to 9 months in combination with standardised compression bandaging.

RESULTS

a total of 86 patients (36 males and 50 females, median age 70 years) were entered into the study. The patient and treatment groups were equivalent for ulcer size, ulcer duration and other characteristics. Cox regression analysis of the time to ulcer healing did not show any difference in healing between platelet lysate and placebo application.

CONCLUSIONS

platelet lysate prepared and delivered by the method used in this study had no influence on the healing of chronic venous ulceration.

Alginate dressings in surgery and wound management: Part 3

This final article in the series looks at the functioning of seaweed-derived dressings at a cellular level, as well as the importance of choosing appropriate secondary dressings

Alginate dressings in surgery and wound management: Part 2

This second in a three-part series looks at the use of seaweed-derived dressings in specific types of wounds

Compression wraps for venous ulcer healing: a review

Compression to the lower extremities is used to increase healing of venous stasis ulcers by improving the blood supply and reducing edema and distension. Compression wraps are available in elastic or non-elastic and in single to multilayer systems requiring varying types of application and exerting different levels of compression. Elimination of edema is so basic and important to venous ulcer healing that the most effective level of compression should be used. Controversy exists regarding the most effective sub-bandage pressure (ranging from 20 mm Hg to 45 mm Hg) for timely healing. Because of differences in compression wraps, selection of the most effective and efficient wrap can be difficult. The purpose of this integrated review was to determine healing rates of venous ulcers with various wraps. The studies reviewed provide reasonable evidence that venous ulcers can be healed with the use of compression wraps and that various wraps are effective when used with correct assessment, application, and fit by the caregiver, along with compliance and mobility of the patient.

Pitfalls in ambulatory phlebectomy

BACKGROUND

Pitfalls, precautions, and technical maneuvers concerning ambulatory phlebectomy are presented in order to facilitate the execution of this procedure.

OBJECTIVE

The objective of this article is to underline certain pitfalls and precautions in the performance of ambulatory phlebectomy in order to minimized morbidity and procure satisfactory results.

METHODS

The author has principally used his experience in more than 4,000 ambulatory phlebectomies as the basis for this study.

RESULTS

The pitfalls and precautions concerning patient selection, operative technique, wound care, and the postoperative compressive dressing are discussed.

CONCLUSION

It is concluded that ambulatory phlebectomy can be performed with minimal complications and will provide a pleasing experience for both the patient and surgeon if certain pitfalls are avoided and precautions are heeded.

Paste-impregnated bandages

A review of the uses of bandages impregnated with paste and their application in the treatment of leg ulceration.