Treatment | Wounds Africa

Treatment of venous ulcers: everything besides compression

If you have read the other chapters on venous ulcers earlier, you will have understood by now that compression treatment is essential to getting venous ulcers to heal. When we see a venous ulcer, we should first think: "what kind of compression device should we use here, and how will I convince the patient to use this every day"? Compression is so crucial that we have dedicated a chapter only to that topic.

In this chapter, we will look at the other parts of the treatment - debridement, choice of dressing and briefly discuss surgical options for treating the underlying venous disorders.

Cleaning and debriding the ulcer

Usually, venous ulcers need to be "cleaned up" when the patient comes to us for the first time. There is often a mixture of fibrin, yellow necrosis, and sometimes even black necrosis, which must be debrided. We have written a chapter about debridement - you will find that under " practical skills" of the menu so that we only write a summary of the key points here.

Debridement of venous ulcers is not a sterile procedure - i.e., you don't need sterile gloves, but you will need regular gloves. A facemask is also recommended as bacteria-laden particles come from our mouth in the form of tiny droplets as we speak during the procedure. We do not want to introduce new bacteria to the wound!

A single-use curette is an excellent tool for debriding. These are very sharp, and you will never have a dull tool because you use a new one each time. However, they are costly. It is much cheaper to use single-use scalpel blades for debridement, but these require a little more skill. Tweezers with small teeth at their end are very useful for holding tissue while cutting. Sometimes small sharp scissors are also helpful in debridement.

Most patients with venous ulcers will find debridement to be a painful procedure. We usually cover the wound in anesthetizing cream or gel ( i.e., Emla cream, lidocaine gel) for about 20-30 minutes before debriding. This will usually not numb the entire wound - remember that these products only numb the outer layers of the wound - but it usually reduces the pain levels so that the patient tolerates the procedure well. There is some ongoing discussion about the effect of these products on open wounds - can they have a negative impact on wounds? There is no scientific evidence that using numbing creams or gels in chronic wounds will have harmful effects. However, when using these products, be aware that you are using them "off-label"- that is, the producers usually do not recommend using them in open wounds.

If you do not have anesthetizing cream or gel available, be aware that administering the patient, for example, paracetamol with codeine about 45 minutes before the procedure may also be helpful.

Suppose the patient finds the procedure painful, although you have used numbing cream and given an oral pain killer. In that case, you should do a serial debridement - only debride a little at each session to make the procedure as pleasant as possible for the patient.

How much should you debride? As a rule of thumb, all not viable tissue should be removed. This requires some experience, and we highly recommend that you learn this from someone used to debriding wounds. However, how much we remove is usually dictated by the patient's pain during debridement. If the patient has little or no discomfort, we can try to debride the wound in one session.

Usually, we rinse the wound before debriding it and afterward. As a rule of thumb: Most venous ulcers do not need an antimicrobial rinsing solution. Clean water is enough. Since the purity of tap water cannot be guaranteed in many parts of Africa, you should use a 0,9% saline solution if this is available to you. If saline solution is not readily available where you work, you can easily make this yourself - we have written a chapter on this.

When should we use an antimicrobial rinsing solution? Many wound care practitioners have misunderstood when an antimicrobial rinsing solution is indicated and have an overrated belief in what it actually does. You must be aware that if you rinse the wound with something antiseptic, you will reduce the number of bacteria - yes, but only for a short period - within a few hours, most of these bacteria will be back. If the wound is not smelly or looks infected, you may even be causing harm to the wound by using antimicrobial rinsing solutions. By reducing the number of "kind" pathogenic bacteria, you may be making space for more aggressive pathogenic bacteria. Using such solutions may actually lead to infection. However, if there are signs of infection or the wound is smelly, reducing the number of bacteria - even only transiently - may be useful.

Figure 1 Debridement is very often a necessary part of treating venous ulcers. Most patients will have some form of discomfort under debridement, and many wound care practitioners use numbing creams/gels in the wound bed before debriding.

Since venous ulcers are usually superficial, there is little danger of damaging underlying structures when debriding. Sometimes you may encounter bleeding from a vein branch in the wound bed. This can sometimes be quite troublesome unless you use a few simple tricks. If you encounter a bleeding vein, remain calm and apply a cotton swab against the bleeding site while at the same time elevating the leg above heart level - the patient should be lying down for this. Keep the pressure on the cotton swab for an entire three minutes. Do not be impatient! Do not take a peek underneath the cotton swab before the three minutes have passed; otherwise, you will have to start over again. If the bleeding has not stopped after three minutes, apply pressure for another three minutes - by then, the bleeding usually has stopped. Very rarely have we needed to place a suture to ligate the vein.

In some cases, the ulcer may be deeper, and tendon or bone may be seen in the bottom of the wound bed. Visible tendon or bone are game-changers! They mean trouble. Unless you are a wound care expert, you should refer this type of patient to a higher level. Luckily this is rarely the case with venous ulcers, and if a venous ulcer is so deep, it usually is more than just a venous ulcer!

Figure 2 In countries where the purity of tap water is guaranteed, this can be used for rinsing most venous ulcers. This is not the case in many areas of Africa, and here you may have access to regular commercially produced 0,9% saline solution or make it yourself. You can also use boiled water ( not hot, obviously!). In only selected cases will you need an antimicrobial agent to rinse these types of wounds. Polyhexanid solutions like Prontosan®, super oxidized water like Veriforte™, Microdacyn 60®, or vinegar-based solutions like Optima ph4 are useful products where you suspect a high level of bacterial burden in the wound.

Taking care of the wound edges

Most venous ulcers have a high volume of exudate, especially when compression treatment is not used. This often leads to moisture-related damage to the skin edges, also known as maceration. The edges of the wound appear paler, and the cells of the wound edges go into a state of dormancy, impairing wound healing from the edges. In many cases, the moisture damage can be extensive, leading to new ulcerations and increasing the wound area in a short time. Managing exudate to protect the wound edges is crucial to treating venous ulcers successfully.

Compression and the correct type of absorbent dressing are the main principles for dealing with excessive exudate. In addition, we can use barrier products to protect the skin edges. Earlier, zinc paste was commonly used as a barrier product around the skin edges. While this is not an old-fashioned product, many wound care practitioners have switched to " invisible" barrier products (like Cavilon®, No-Sting Barrier®, or Silesse® ), which come in the form of pre-moistured lollipops or as sprays and are a little more practical. These are, however, obviously more costly than using regular zinc paste.

Zinc paste is still a very good alternative in a setting with limited resources. For this use, a zinc paste with 40% zinc is optimal. In fact, some studies show that the effect of topical zinc oxide may be beneficial for the healing process - so zinc oxide paste is by no means an inferior choice! This is quite a thick product that adheres well to the skin and, in this way, prevents the zinc paste from absorbing into the dressing within a few hours. If you only have a product with less zinc available, you will have to use that. If you do not have zinc paste available, you can use vaseline around the skin edges - this is available in every corner store in Africa and is very cheap.

Figure 3 Protecting the skin edges with some form of barrier product is essential with wounds with high exudate to prevent maceration of the skin. Many products are available for doing this - modern versions come as sprays or lollipop foams saturated with the product. Zinc paste is not in any way old-fashioned - the best zinc pastes for this use should have a zinc content of about 40%.

Addressing venous dermatitis

As mentioned earlier venous dermatitis ( also known as stasis dermatitis) is a common condition in patients with venous insufficiency. The skin becomes warm and reddish ( inflamed). This is often due to a combination the edema irritating the skin layers and irritation from moisture exudating from the wounds. When the skin is aggravated in such a manner, new ulcers can appear within a short time, and it is essential to calm down the skin as quickly as possible. Compression treatment is necessary here, but we often use zinc-based creams or steroid creams beneath the compression bandages.

In cases with mild dermatitis, zinc paste ( in combination with compression) may be sufficient. Zinc has anti-inflammatory properties and often also helps against itching. Apply zinc paste liberally over all areas which are reddish/itchy. Usually, the combination of zinc and compression therapy will lead to an improvement after only a few days.

Some bandages are already impregnated with zinc paste. These bandages are applied loosely around the entire leg and then covered with a compression bandage. Another alternative is stockings which also are impregnated with zinc. The advantage of these products is that they are easy to apply, and the zinc paste stays nicely in place for up to a week.

You can make a zinc stocking by applying zinc paste liberally to the whole leg and then using a cotton stockinette over this.

If the wound has a high amount of exudate, which demands daily dressing changes, we recommend applying zinc paste directly to the affected leg as ready-made products will be too costly.

Figure 4 This patient has venous insufficiency and has developed several small ulcerations on both legs with moderately inflamed dermatitis. There is little exudate coming from the ulcers and we are planning weekly dressing changes. We have made a 50:50% mixture of Dermovate ( a class IV corticosteroid cream ) and zinc paste. First, we apply this directly to the leg, then cover this with a stockinette. To make sure that the zinc/dermovate combination does not absorb into the compression dressing, we apply another layer on the outside of the stockinette. After this, we applied a short-stretch elastic compression bandage directly over this.

Figure 5 A choice of different commercially available bandages pre-impregnated with zinc oxide. Note that there are differences in concentrations of zink oxide between the various products. When we use zinc oxide as a barrier product around the wound edges, we prefer 40% zinc oxide. When we cover the leg with zinc oxide to reduce inflammation, 20% zinc oxide is sufficient. Ichtopaste® is different from the others in that it contains an antimicrobial agent - Ichtammol - which has anti-inflammatory, bactericidal, and fungicidal properties.

If the venous dermatitis is more pronounced, we recommend using steroid creams directly on the skin and on superficial ulcerations. When we ( the authors of wounds Africa) first started our careers in wound care, we thought corticosteroids always impair wound healing. At medical school, we were taught that topically applied steroids could impair the immune response locally, cause thinning of the skin, and other side effects. Today we have another view of this. Yes, topical steroids can have a negative impact on the skin when used for a long time. Systemically administered steroids will also have a negative effect on the immune system and cause thinning of the skin. However, if used correctly and over a short period - for example, up to 4 weeks we haven't seen any adverse reactions. We have noted a superior effect on reducing dermatitis and a speeding up of the epithelialization process when applying steroid ointments to venous dermatitis. Read that again - yes, we actually see an improvement in the speed of healing when we use steroid ointments! But only if you use it in the correct situation in venous ulcer/venous dermatitis that is stalling due to excessive inflammation! As a side note - another situation where steroid ointments are the treatment of choice is hyper granulation - but that is part of another chapter.

Steroid ointments come in 4 grades. Grade 1 is the weakest, and grade 4 is the strongest. In our experience, you will be wasting the patients and your time if you try grad 1 steroid ointments in pronounced venous dermatitis. We recommend a 10-14 period with grade 3 or 4 steroid ointments. In milder cases of dermatitis, you can try a weaker steroid ointment, for example, grade 2, but in our experience, grade 1 products are too weak for any form of venous dermatitis.

A tip from our clinical practice is to mix a grade 3 or grade 4 steroid cream together with 40% zinc oxide paste, usually in a ratio of 1:1 ( one-part steroid ointment and one-part zinc oxide paste). This will also work if you have a zinc oxide ointment with a lower percentage of zinc oxide. We apply this mixture liberally over the areas where there is redness, cover this with a stockinette, and apply a compression bandage. Of course, making such a mixture is an off-label use of these products, and there are no studies to show that this is a good practice. You will have to take our word for it while we cannot accept any liability for its use. We will always have to make this disclaimer regarding the off-label use of products. In wound care, many products are used off-label because we sometimes have to improvise when we are in tricky situations.

Some steroid ointments contain antimicrobial agents - for example, Betnovate with chinoform. Steroid ointments with antimicrobial agents should not be used to treat a general infection in the affected leg, nor should they be used prophylactically to prevent future infection. The indications for these products are situations where you have venous dermatitis and suspect there to be a superficial bacterial or fungal infection that has not penetrated the deeper layers of the soft tissues.

Figure 6 In cases with mild venous dermatitis, it is often sufficient to treat this with zinc ointments. If there is more pronounced dermatitis, you will need corticosteroid ointments. Some steroid ointments have antimicrobial ingredients, but these products should only be used when you suspect a superficial bacterial or fungal infection.

Dressing choice- venous ulcers with a high amount of exudate

Venous ulcers often have a high amount of exudate, which is the most important aspect to consider when choosing an appropriate dressing.

We have to get control over the ulcer to make it turn towards a healing path. The key to this is compression treatment, protecting the skin edges from moisture-related breakdown, and a good absorptive dressing. In the start you may have to change the dressing often, sometimes several times a day. As a rule of thumb, rather change the dressing too often in the start rather than too seldom. In many healthcare settings in Africa, it is completely unrealistic to expect the patient to return to your clinic or dispensary several times a day, and home-care nurses are non-existing in most rural parts of the continent. Your only choice is to teach the patient or a relative how to do the dressing changes and apply the compression bandage! From our experience, this works very well, and the patients/relatives soon become experts at treating the wound and notice if something is wrong in the course of the treatment.

So-called super absorbant dressings are the top choice for ulcers with high exudate - these can absorb more fluid than regular dressings and lock the fluid in the core of the dressing away from the wound and skin edges. They work much like modern diapers, which also lock fluids in the middle of the dressing protecting the baby's bottom from moisture damage. These super absorbent dressings are relatively expensive and are probably not a realistic option for many African patients.

Since we just mentioned diapers - we have sometimes had to use diapers in the initial phases of treating huge venous ulcers where the exudate amount was too high to handle for most dressings! A diaper can, in other words, become an emergency solution for treating complicated venous ulcers! In Tanzania, a 60 diaper pack (Huggies Size 4) costs about 18 US Dollars at the online pharmacy dawa.co.tz - that means a diaper there costs 30 cents. For large wounds, you may use a whole diaper. If the ulcer is smaller and you have nothing else as a good absorbent agent, you may have to resolve to cutting the diaper into smaller pieces. If you have ever cut up a baby's diaper, you will know that the layers fall apart, so you will have to strengthen the edges with tape. If you have to improvise because of minimal resources, you could even sow the edges together with a sewing machine. Note that an intact diaper is designed not to leak fluid from the edges - if you improvise like above and sew the edges together, this will not be leakproof. If the diaper dressing is saturated with fluid, it will leak out at the edges. Homemade diaper dressings need to be changed more often to prevent moisture-related skin damage. Note that if you are using compression, the exudate amount should gradually decrease within 7-10 days, and you can go over to using a more conventional dressing.

Figure 7 There are many excellent super absorbant dressings on the market intended for wounds with a high amount of exudate. They also have in common that they are quite expensive and will not be a realistic option for most of your patients. As a cheaper improvised alternative, your patient may have to use baby diapers around the ulcer if the exudate situation is out of control.

Dressing choice- venous ulcers with moderate or low amounts of exudate

When there is less exudate, we have many choices of dressings, which will work well. Of all dressing types, there is only one, in particular, you should not use - hydrocolloid dressings. These are very occlusive dressings that trap fluid underneath, and these are contraindicated for venous ulcers, in our opinion. Hydrofibre or alginate dressings can be used without moisturizing them before placing them into the wound. These products absorb fluid, turning the fibers into a gel-like consistency. However, you will need a secondary bandage to cover these when using such products. Therefore, it is often more practical to use a polyurethane foam dressing which is a suitable allround dressing type. They absorb pretty well and work well under compression dressings. If you suspect the bacterial burden to be high, you can choose a polyurethane foam dressing with silver or PHMB.

It may be useful to know that one type of polyurethane dressing - Biatain Ibu - contains Ibumetin, an anti-inflammatory agent ( a type of NSAID) with pain-reducing properties. In our experience, only under half of the patients feel good pain relief when using this dressing, but it is worth a try. While most patients with venous ulcers have some degree of pain, most do not have very severe pain. If your patient with a suspected venous ulcer complains about much pain, you will have to reconsider your wound diagnosis - is it really a venous ulcer? Could it have an arterial (ischemic component)? Can it be a mixed ulcer, tropical ulcer, or even a malignant ulcer

What can you do if you are working in a healthcare setting with limited resources and do not have access to these kinds of dressings? For one, you could use the improvised diaper dressing, as we mentioned earlier. If that is not an option for your patient either, and your only choice is cotton gauze, you will have to manage with this. Cotton gauze or compresses can be used in all types of wounds really -their disadvantages are mainly that they do not transport fluids well enough away from the wound area - that is - when the cotton pad is saturated the wound area gets really wet and moisture associated skin damage is a danger. You can increase the amount of cotton compresses so that fluid is hopefully wicked better away from the wound area. Remember, however; you cannot make a too big lump of cotton since you will have to have a compression bandage over this. Another disadvantage with cotton as a wound dressing is that it may adhere to the wound bed making dressing changes painful and possibly stripping the wound bed of healthy growing tissue. You may argue that you want to use cotton as a wet-dry type dressing- that is, that you intentionally want to let it adhere to the wound bed so that you, in effect, debride the wound bed as you remove the cotton. Wound care has generally moved away from this principle, with only a few followers remaining. None of the editors of Wounds Africa recommend using the wet-dry principle anymore.

When using cotton pads as a dressing, you can spread a thin layer of vaseline on the innermost layer of the cotton to minimize the adherence of the cotton to the wound bed. Do not use too much vaseline as this can hinder the absorption effect of the cotton gauze. Also, change the cotton gauze dressings often so that they do not adhere to the wound as much!

If you only have cotton gauze and want an antimicrobial effect, you can put some honey into the wound first and then cover it with the gauze. Do not overdo it with the honey - a shallow layer is enough - too much honey will lead to increased exudate as the sugar from the honey has an osmotic effect. When using cotton gauze, the dressing needs to be changed often anyway, so honey can be re-applied at each dressing change.

You only have cotton gauze, and you want to make a smell neutralizing dressing? No problem - you can sprinkle active charcoal in between layers of the cotton gauze, neutralizing some of the odor. If you don't have activated charcoal, you can use crushed regular charcoal.

We are not saying that cotton gauze is a good alternative to the other dressings. We are saying that if you only have cotton gauze available, you can actually manage as long as the dressings are changed very often.

Figure 8 Polyurethane foam dressings are good all-round dressing for venous ulcers with moderate-low exudate levels. Most of these products also come with antimicrobial alternatives like silver or PHMB for use in wounds with a high bacterial burden.

Dressing choice- venous ulcers, which are smelly

Sometimes a venous ulcer can be smelly to the degree that it causes discomfort to the patient and those around them. The smell derives from bacteria that thrive in a moist environment, and the bacteria break down proteins that are contained in the wound exudate. The smell that comes from the breakdown of proteins in exudate is usually more " fishy" or may resemble the smell of prawns which are a few days over the expiry date.

If the reason for the smell is the exudate and not dead tissue in the wound, then it will help to rinse the ulcer regularly. This can be done using a showerhead in areas where tap water is of drinking quality. In other areas, you will have to use boiled water. A tip is to add vinegar so that the water contains 2% vinegar after dilution. Regular household vinegar can be used for this purpose. Household vinegar typically contains 5-8% acetic acid. Let us assume the vinegar you purchase at your local shop contains 5% acetic acid to make the mathematics easy. If you use 100ml of this vinegar and dilute it with 100ml boiled water ( which has cooled down), you will have a 2,5% acetic acid solution which is close enough.

Other antimicrobial rinsing solutions like polyhexanide and super oxidized water will also help to reduce smell temporarily.

Sometimes the reason for the smell is that there is much dead tissue in the wound, which is being broken down by bacteria - then the smell is more like rotting meat. If there are predominantly enterococci in the wound, it will often smell more like excrements. You can rinse the ulcer all you want- if there is much dead tissue, the smell will come back. You have to debride as much of the dead tissue as possible to manage the smell problem.

When the wound is smelly, your choice of dressing should contain something that has antimicrobial activity. Please refer to the chapter on antimicrobial dressings for a complete overview of these products. Many products contain colloidal silver as an antimicrobial agent; some contain polyhexanid or bismuth. However, these will not do miracles for the smell - they will help reduce it somewhat.

Another product group that is useful for treating smelly venous ulcers is dressings containing active charcoal. The charcoal neutralizes many odor-causing bacterial products that derive from bacteria and locks them within the charcoal. Again these sorts of products may not be available to you. We have used a workaround to buy active charcoal powder ( which can be obtained relatively cheaply) and fill this into an opening we made in a multilayered dressing. The small hole in the dressing is closed with tape.

Changing the dressing often will, in general, also help with odor problems. Sometimes the odor actually comes from within the dressing.

The smell is usually not enough indication to start with antibiotic treatment unless there are other signs of infection! In some literature, authors have recommended sprinkling crushed metronidazole (antibiotic) pills into smelly wounds. While this actually will help reduce the smell somewhat, it will simultaneously lead to the development of resistant bacteria- so do not use it for this purpose!

Figure 9 Wound dressings with activated charcoal can, to some degree, neutralize the odor from wounds. The differences between the dressings shown above are how much exudate they can absorb. When treating venous ulcers, which usually have much exudate, the charcoal dressing should at the same time have high absorptive properties.

Also, do not use perfume or aftershave to cover the odor from a wound - it will only make for a disgusting mix of olfactory sensations! Trust us- we have tried.

An exciting product is a spray produced in Norway called Ynolens, which claims to neutralize all forms of offending odors for several hours. We have tried this in a clinical setting and can confirm that it works very well. According to the producers, it contains nothing harmful to the wound itself nor if it is inhaled by humans. It is not meant to be sprayed directly into the wound but can be sprayed on the skin in close vicinity to the wound and can be sprayed onto the outside of dressings. Click on the image below to get to the company's website.

Figure 10 Wound dressings Ynolens is an innovative odor neutralizing spray which can be applied in close vicinity of wounds. It contains no harmful ingredients to the skin or airways when inhaled. We have tried it in a clinical setting with very convincing results. Obviously, this product is no substitution for addressing the reason for the odor in the wound itself. Click on the image above to get to the producers' website www.ynolens.com

Treating venous ulcers with negative pressure wound treatment (NPWT)

In a healthcare setting with the most resources available, using NPWT for treating venous ulcers is an excellent alternative. It may seem like an expensive treatment modality, but when used correctly, it is actually one of the cheapest alternatives. This may seem ironic, but the calculation is based on the fact that NPWT often speeds up the healing process manifold. Consider a venous ulcer that may take 6-12 months to heal under regular treatment instead of a healing time of maybe three months when using NPWT. Adding the costs of the prolonged healing time when not using NPWT ( transport to clinic, costs at clinic, time taken off work, possibly sick leave, costs of dressings) can be considerable. The calculation above considers all the socio-economic costs, which are obviously of little use to you when you are investing in NPWT pumps or if the patient has to purchase these.

We will not go into detail about using NPWT here since we have written a thorough chapter on the indications and use of NPWT. When we started using NPWT about 15 years ago, we only had one type of pump available. Today there are over 100 different pump models to choose from - from tiny pumps that are independent of a power source ( mechanically driven) to big heavy pumps with advanced functions.

When used correctly and on the right type of ulcer, no other modality can deliver results as quickly as NPWT! Using NPWT aims to stimulate the wound to produce granulation tissue as quickly as possible. Note that NPWT does not help in getting skin to grow over the wound! Once the wound has nice granulation tissue, it is time to stop the NPWT treatment. Treatment with negative pressure is also an excellent modality to control wound exudate and move it away from the wound and surrounding skin. When we use NPWT on venous ulcers, the wound bed has to be relatively well debrided, and there should be no signs of infection.

We often use partial-thickness skin grafts to cover venous ulcers in our clinic. In these cases, we use NPWT to prepare the wound bed so that the skin graft takes better.

Using partial-thickness skin grafts on venous ulcers

Again, this is a treatment modality that only is applicable if you work at a clinic where these resources are available. Venous ulcers are usually superficial and respond well to skin grafting. We have written a separate chapter on skin grafting - please refer to that chapter for more detailed information about how this is done. Here we list some of the key points to consider when using skin grafts on venous ulcers.

The wound has to have healthy granulation tissue over the entire wound bed.

Note: hyper granulation is not suitable for skin grafting. If there are signs of hyper granulation, you need to address this first. We have written a separate chapter on hypergranulating wounds - please refer to this chapter if you want to know more about this condition.

If there are signs of infection, the skin graft will fail- address the infection first.

The graft will fail if there are signs of increased bacterial burden in the wound- address this first. If the wound has a smell that is "off," do not attempt a skin graft- it will fail. Get the wound clean first.

If the patient does not use compression treatment, the graft will most likely fail. Compression is obligatory when skin grafting on venous ulcers.

If the ulcer has a high amount of exudate, the graft will fail - you have to wait until the level of exudate is low before attempting a skin graft.

The patient must be informed that they will get a scar at the donor site where the partial-thickness graft is taken from.

Remember that you do not always have to do a traditional split-thickness graft. Some mini-invasive methods, such as blister grafts or pinch-punch grafts, can easily be redone if the first try does not yield results. In the chapter on skin grafting, we discuss the different methods.

Vein surgery for treating venous ulcers

In a healthcare setting where all resources are available, patients with venous ulcers who do not respond to regular treatment with compression and good dressings are referred to vascular specialists. Here the patient will be examined for the presence of dilated insufficient veins, which are in direct communication with the ulcer area. These insufficient veins may be visible without aids ( i.e., varicose veins) or may lie deeper such as perforating veins that are only visible using, for example, ultrasound techniques.

In some cases, a venous ulcer will not heal unless the insufficient veins are treated surgically. We will not go into detail about the surgical alternatives here because most of our readers will not be involved in the surgical treatment of vein disorders.

Shortly summarized - with today's available surgical methods, we usually try to do these with endovascular techniques. These are mini-invasive procedures usually done in an outpatient setting or as day-care surgery in local anesthesia. Some methods involve using radio-frequency, laser, steam, foam, or glue to close insufficient veins. Smaller veins can be treated using ultrasound-guided injection methods with substances like polidocanol (aetoxysclerol). In some cases, open surgery is needed.

While these types of surgical treatments are performed at some hospitals and private centers in Africa, they are not available to the majority of the patients there. If you work in a clinical setting where this type of surgery is not an option, you have to do the best out of the means you have available. Ensure that the patient really understands that compression treatment is the key to success and that they use it daily.

We have written a separate chapter on surgical treatment of incompetent veins - please refer to that for more details.

Figure 11 A recent article on venous ulcers published in september 2023. This article gives a good overview of the main treatment principles. Click on the image to go to a link of the public article.