Treatment of venous ulcers 

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.  The first thing we should think when we see a venous ulcer is : "what kind of compression device should we use here and how will I convince the patient to use this every day"? Compression is so important that we have dedicated a chapter only for 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

It is very usual that venous ulcers need to be "cleaned up" when the patient comes to us for the first time. There is very often a mixture of  fibrin, yellow necrosis and sometimes even black necrosis which needs to 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 dont 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 small 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 because you use a new one each time you will never have a dull tool. However, they are costly.  It is a lot cheaper to use single-use scalpel blades for debridement but these require a little more skill to use. Tweezers with small teeth in the end are very useful for holding tissue while cutting. Sometimes small sharp scissors are also useful in debridement.

  • Most patients with venous ulcers will find debridement to be a painful procedure. We usually cover the wound in anesthesizing cream or gel ( i.e. emla cream, lidocaine gel) for about 20-30 minutes prior to debriding. This will usually not numb the entire wound - remeber 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 in open wounds - can they have a negative impact in wounds. To date 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 the "off-label"- that is the producers themselves usually do not recommend using these in open wounds

  • If you do not have anethesizing 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.

  • If the patient finds the procedure painful although you may have used numbing cream and/or given an oral pain killer you should do a serial debridement - that is only remove a little at each session to make the proocedure as pleasant as possible for the patient.

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

  • Usually we rinse the wound prior to debriding it and afterwards. 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 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? Here a lot of woundcare practitioners have misunderstood when  an antimicrobial rinsing solution is indicated and have a a overrated belief in what it actually does. You must be aware that if you rinse the wound with something antiseptic then you will reduce the amount of bacteria - yes, but only for a short period of time - 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 woundcare practitioners use numbing creams/gels in the woundbed prior to debriding.

Since venous ulcers usually are quite superfiscial there is little danger of damaging underlying structures when debriding. Sometimes you may encounter bleeding from a vein branch which lies 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 utherwise you will have to start over again.  If the bledding has not stopped after htree 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 som case 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 woundcare 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 the tap water is guaranteed this can be used for rinsing most venous ulcers. In many areas of Africa this is not the case 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 really need an antimicrobial agent to rinse these type 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 there to be 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 of 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 short time.  Managing exudate to protect the wound edges is crucial to treating venous ulcers successfully.

Using compression and the right type of absorbant dressing are the main principles to deal 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 of a wound. Whilst this is in no way an old fashioned product many woundcare practitioners have switched to " invisible" barrier products                (like Cavilon®, No Sting Barrier® eller Silesse® ) which come in 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.

In a setting with limited resources zinc paste is still a very good alternative.  For this use a zinc paste with 40% zinc is optimal. Infact, 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 which 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 prducts with less zinc available you will have to use that of course. If you do not have zinc paste available at all you can use vaseline around the skin edges - this is readily 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.  A large number of  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%. 

Adressing 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 aggrevated in such a manner new ulcers can appear within short time and it is important to calm down the skin as quickly as possible.  Compression treatment is essential here but often we also 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. 

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

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

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

Figure 4 Et  A choice of  different commercially available bandages which are 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 prduct 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® iis 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 superfiscial ulcerations.  When we  ( the authors of wounds africa) first started our careers in wound care we thought that cortikosteroids always impair wound healing. At medical school we were taught that topically applied steroids can impair the immuneresponse 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 impact on the immune system and cause thinning of the skin.  However, if used correctly and over a short period of time - for example up to 4 weeks we havent seen any adverse reactions and have noted a superior effect on the reduction of dermatitits 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- which is in venous ulcer/venous dermatitits that are stalling due to excessive inflammation!  As a sidenote - another situation where steroid ointments are the treatment of choice is hypergranulation - but that is part of another chapter.

Steroid ointments come in 4 grades.  Grade 1 are the weakest, grade 4 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. Here we recommend a 10-14 period with grade 3 or grade 4 steroid ointments.  In milder cases of dermatitis you can obviously 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 own 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).  If you have a zinc oxide ointment that has a lower percentage of zinc oxide this will also work. This mixture we apply liberally over the areas where there is redness, cover this with a stockinette and apply a compression bandage over. Making such a mixture is ofcourse 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 take any liability for its use.  We will always have to make this disclaimer when it comes to off-label use of products.  You will find that in woundcare many products are used off-label because we soemtimes 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 a future infection.  The indications for these products are situations where you have a venous dermatitis and suspect there to be a superficial bacterial  and/or fungal infection which has not penetrated into the deeper layers of the soft tissues. 

Figure 5  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 and/or fungal infection. 

Dressing choice- venous ulcers with high amount exudate

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

We have to get controll over the ulcer to make it turn around towards a path of healing.  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 to seldom. In many healthcare settings in Africa it is completly 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 babys bottom from moisture damage. These super absorbant dressings are fairly 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 to 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 absorbant agent you may have to resolve to cutting the diaper into smaller pieces.  If you have ever cut up a babys diaper you will know that the layers fall apart so will have to strengthen the edges with tape. If you have to improvise becuase of very limited resources you could even sow the edges together with a sewing machine. Note that an intact diaper is designed to not leak fluid from the edges - if you improvise like above and swe the edges together this will not be leak proof.  Ifv the diaper dressing i 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 if you are using compression the exudate amount should gradually decrease witrhin 7-10 days and you can go over to using a more conventional dressing.

Figure 6  There are many excellent super absorbant dressings on the market which are intended for wounds with 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 amount 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 whcih 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 dressing turning the fibres into a jelly-like consistency. However when using such products you will need a secondary bandage to cover these.  Therefore it is often more practical to use a polyurethane foam dressing which is a good allround dressing type. They absorb quite 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 which is an antiinflammatory 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.  Whilst most patients with venous ulcers have som degree of pain most do not have very strong pain. If your patient with a suspected venous ulcer complains about a lot of 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 malignt ulcer

If you are working in a healthcare setting with limited resources and you do not have access to these kind of dressings - what can you do? 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 are cotton compresses then you will have to manage with these. Cotton gauze or compresses can be used in all types of wounds really -their disadvantages are mainly that they do not transport fluids good 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 try to increase the amount of cotton compresses so that fluid hopefully is wicked betetr 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 dresing changes painful and possibly stripping the woundbed 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.  In general woundcare has moved away from this principle and it has only few followers. 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 coton gauze dressings often so that they do not adhere to the wound as much!

If you only have cotton gauze and you 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 then 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 and it will neutralize some of the odour. If you dont have activated charcoal you can use crushed regular charcoal. 

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

Figur 7 Polyurethane foam dressings are good allround 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 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 the patient. The smell derives from bacteria that thrive in the moist environment. 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 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.  In areas where tap water is of drinking quality this can be done using a shower head. 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.  To make the mathematics easy let us assume the vinegar you purchase at your local shop contians 5% acetic acid.  If you use 100ml of this vinegar and dilute it with 100ml boiled water ( which has cooled down) then 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 reduse smell temporarily.

Sometimes the reason for the smell is that there is a lot of dead tissue in the wound which is being briken 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 a lot of dead tissue the smell will come back. To manage the smell problem you have to debride as much of the dead tissue as possible. 

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

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

 

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

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

Figur 8 Wound dressings with activated charcoal can to some degree neutralize odour from wounds. The differences between the dressings shown above are how much exudate they can absorb.  When treating venous ulcers which usually have a lot of exudate the charcoal dressing should at the same time have high absorptive properties. 

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

An interesting product is a spray produced in Norway called Ynolens which claims to neutralize all forms of offending odours 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 that is 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 companies website.

wounds africa ynolens.jpg

Figure 9 Wound dressings Ynolens is an innovative odour neutralizing spray which can be applied in close vicinity of wounds. It contains no harmful ingredients to neither skin or airways when inhaled. We have tried it in a clinical setting with very convincing results. Obviously this product is no substitution for adressing the reason of the odour 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 where you have 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 ironical 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 as opposed to a healing time of maybe 3 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 is taking all the socio.economic costs into consideration which is obviously of little use to you when you are investing in NPWT pumps of if the patient has to purchase these. 

We are not going to 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 which are independent from a power source ( mechanically driven) to big heavy pumps with advanced functions.

When used correctly and on the right type of ulcer there is no other modality that can deliver results as quickly as NPWT!  The aim of using NPWT is 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 fairly well debrided and there should be no signs of infection.

In our own clinic we often use partial thickness skin grafts to cover venous ulcers. 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 which only is applicable if you work at a clinic where these resources are available.  Venous ulcers are usually superfiscial and respond well to skin grafting.  We have written a seperate 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: hypergranulation is not suitable for skin grafting. If there are signs of hypergranulation you need to adress this first. We have written a seperate chapter on hypergranulating wounds - please refer to this chapter if you want to know more about this condition.

If ther are signs of infection the skin graft will fail- adress the infection first.

The graft will fail if  there are signs of increased bacterial burden in the wound- adress 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 has to be informed that he/she 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.  There are some mini-invasive methods such as blister grafts or pinch-punch grafts which can easily be redone if the first try did not yield results. In the chapter on skin grafting we discuss the different methods to choose from.​​​​

Vein surgery for treating venous ulcers

 

​In a healthcare setting where all resources are available patients with venous ulcers which do not respond to regular treatment with compression and adequate dressings are referred to vascular specialists. Here the patient will be examined for the prescence 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 which 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 of the surgical alternatives here because the majority of our readers will not be involved in the surgical treatment of vein disorders. 

Shortly summarized - with todays available surgical methods we usually try to do these with endovascular methods. These are mini-invasive procedures which are 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.​

Whilst these type of surgical treatments are performed at some hospitals and private centres 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 to 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 he/she uses it daily.

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