Management of infection control in leg ulcer Essay

Management of infection control in leg ulcer
Introduction
A leg ulcer is an area of skin on your lower leg, heel or foot that has broken down so that the tissue beneath is visible. Leg ulcers appear like shallow holes or craters, and can differ in size, colour and depth.

Majority of leg ulcers develop due to poor circulation in your legs, either within the veins (causing venous leg ulcer) or the arteries (causing arterial leg ulcer). Individuals with diabetes are also at particular risk of leg ulcers.

Leg ulcers become more common as you grow. Of individuals aged 61-70, about 3 out of every 1000 will develop a leg ulcer at any one time, and this rises to 20 out of every 1000 for individuals aged 80 and above. Even though leg ulcers are often thought to only affect the elderly, about 20% of those who develop a leg ulcer are less than 40 years of age.

Women are more prone to leg ulcers than men.

Symptoms
Leg ulcers have dissimilar symptoms depending on their cause. Arterial leg ulcers mostly develop on the feet, heels, the tips of the toes, between the toes, or where the bones of the feet stick out and rub against bedcovers, socks or shoes. Arterial ulcers are very much common where the toenails come into contact with the skin of the toes.

An arterial ulcer usually has a distinct appearance. Their surfaces do not usually bleed, but may have a yellow, brown, grey or black colour. The edges of the ulcer are usually levelled, and are often described as looking like they have been ‘punched out’.

Arterial leg ulcers are generally painful, mainly when your legs are at rest or are raised (for example at night). Your foot and lower leg may feel cold, and turn a bluish or whitish colour. ( Khachemoune A, 2001)

Venous leg ulcers usually grow below the knee, often on the inner part of the leg just on top of the ankle. The leg will usually swell before the appearing of a venous ulcer.

The ulcer may pour out fluid, or may be covered in a yellowish-grey coating. The base of the ulcer is generally red, the edges not level, and the skin surrounding it may be dry, scratchy, swollen and discoloured.

The skin on the lower leg may turn a brown or purplish colour, or brown spots and patches would appear. The skin may also appear shiny and tight.

A venous ulcer will cause pain only if it gets infected. However, if your ulcer has occurred by venous problems it is common for your leg to ache.

Diabetic leg ulcers most commonly grow on the bottom of your foot, although they can develop anywhere on your foot or lower leg that suffers a cut or minor wound.

Maessen-Visch MB, 1999 believes that the base of a diabetic ulcer can vary in form, depending on how excellent the circulation in your leg and foot is. It may show pink/red or brown/black. The boundaries of the ulcer are usually levelled or ‘punched out’, and the skin surrounding it often becomes thicker and harder.
All leg ulcers are open to infection, as the natural protection provided by the skin has disappeared. Infected ulcers mostly display yellow crusts on their surface, or green or yellow pus, and they usually smell unpleasant. The part around the ulcer may turn out to be tender, warm, red or swollen. (Angle, N. Bergan, JJ. 1997)

Causes
Venous leg ulcer according to research conducted by Wunderlich RP 1998  says that, around 70% of leg ulcers are venous ulcers. Venous leg ulcers develop when the valves in the larger veins of your leg – which normally make sure that blood can only flow up your leg in the direction of your heart – stop functioning properly.

When this happens, blood flows back down through the damaged valves and pools in the minor veins next to the skin in the lower part of your leg. This increases the pressure in these minor veins until fluid is forced out of them. The skin becomes damaged and swelled because of the fluid. The damaged skin becomes thin and inflamed, and can sooner or later break down to form an ulcer. (Reiber GE. 1996)

Some individuals are born with poor valves, but they can be damaged by:

a fracture, cut or an injury to the leg,
a blood clot in the deep veins of the leg,
long periods spent sitting or standing,
surgery,
obesity, and
Pregnancy.
Following factors increase your risk of developing a venous leg ulcer:

high blood pressure,
varicose veins,
the valves in your legs become weaker with age,
smoking – tobacco is known to affect your circulation,
some cardiovascular medicines can affect your circulation,
History of venous leg ulcer.
Arterial leg ulcer

Around 20% of leg ulcers are arterial ulcers.

Proposed by Tyrrell MR, Wolfe JHN. 1993, writes in arteries transmit blood from your heart throughout your body. If the arteries in your leg turn narrow they may be unable to carry enough oxygen and nutrients to the tissues of your lower leg and foot. This leads to unhealthy skin, which is likely to form an ulcer.

According to Alb rant, 2000 the universal reason for arteries to turn narrow is atherosclerosis – a disease of the arteries that causes fatty substances to develop inside them. However arterial leg ulcers can be made worse by:

smoking,
high blood pressure,
high cholesterol,
diabetes,
rheumatoid arthritis,
stress,
obesity
old leg ulcers,
Coronary heart disease.
Around 10-15% of leg ulcers have a mixture of venous and arterial causes.

Other causes

Diabetic patients are more prone to leg ulcer.  Diabetic leg ulcers develop as a consequence of the narrowing of the leg arteries and nerve damage that is caused by diabetes. The narrowing of the leg arteries can lessen the blood supply to your feet and legs. Skin with a poor blood supply does not heal well. The result is that if you are diabetic and suffering from a minor cut or injury on your foot or lower leg, it can take longer to heal, and is more likely to form an ulcer. As diabetes can cause reduced sensation in your feet you are also less likely to detect a leg ulcer in its early stages. (London N J. Donnelly R. 2000)

Diabetic leg ulcers are more likely to cause if diabetes is not well-controlled by diet or medication.

Treatment
The treatment for venous and arterial leg ulcer is different and treating either type erroneously can be unsafe. A visit to the doctor is necessary if you have a leg ulcer. They will be able to recognize which type of ulcer you have and advise you on the correct management.

Management for leg ulcer aims to treat the factors that have caused the ulcer. While the ulcer is being treated, it should be cleaned and dressed. Most individuals with leg ulcers can be treated at home, with only about 5% needing hospital management. (Caputo GM, Cavanaugh PR, 1995)

General treatment

Whatever the cause of your ulcer, keeping it clean is necessary. A variety of dressings are available to suit the different types of ulcer and different stages of healing.

Suggested by the writer Goldstein DR. Vogel KM. Mureebe L. Kerstein MD. 1998 that dressings are usually changed weekly, excluding those ulcers that are infected and those that produce a great amount of fluid may require the dressing changed more frequently, sometimes as frequently as every few hours. Your doctor may perhaps arrange to have a nurse visit you at home to change your dressing.

Writers Armstrong DG. Lavery LA. Vela SA. Quebedeaux TL. Fleischli JG. 1998 proposed the research that the skin surrounding your ulcer may be dry, scratchy and scaly. Your doctor may advise a moisturiser or prescribe a steroid ointment for you to use on the skin around the ulcer, but not on the ulcer itself. They possibly will prescribe painkillers if your ulcer is causing pain and antibiotics if the ulcer is infected.

For your skin to be able to heal well, your body requires protein, zinc and vitamins B and C. If you are a smoker you must stop smoking as the chemicals in cigarettes can hinder with the normal skin healing process. (Sibbald RG, 2001)

Depending on the size and location of your ulcer, your doctor would advice you to wear special shoes, specially cushioned insoles, or a cast for your lower leg. These would help to take the pressure off your ulcer plus allow it to heal better.

Venous leg ulcer

Venous leg ulcers are treated with exercise, keeping your lower leg raised, and compression therapy.

Muha J. Local 1999 believes that compression therapy is the most significant part of the treatment. A compression bandage is usually used. The bandage is wrapped commencing from your toes or foot, up your lower leg to below your knee. Numerous layers of bandage are used, with the pressure highest at your ankle and becoming gradually less near your knee. The weight of the bandage on your leg helps to carry the blood from your lower leg back to your heart.

When you are resting your leg should be raised higher than your hip. This helps gravity pull blood and fluid back to your heart, hence reducing the swelling in your leg. When you retire for bed at night your legs should be raised – try resting them on a couple of cushions.

Around 7 out of 10 venous leg ulcers are cured within 12 weeks when treated with compression therapy. Yet, it is common for venous leg ulcers to return once they have healed. For prevention, your doctor may suggest you to wear a compression stocking throughout the day for several months, or years, after the ulcer has cured. (Sonmezoglu K, 2001)

Arterial leg ulcer

Addressed by American Diabetes Association during a conference held in 1999 showed that arterial leg ulcers are treated by correcting the cause of the ulcer and by encouraging it to heal properly by cleaning it and keeping it dressed. Compression therapy is not suitable for arterial leg ulcers.

The pain of an arterial leg ulcer can be reduced by sitting on the edge of a chair or a bed with your feet resting on the floor.

Edelman D, Etchells E, Cornuz J, Simel DL. 1999, proposed that in some cases surgery may be required to correct the narrowing of the arteries that causes arterial leg ulcer. The most familiar procedure is balloon angioplasty, where a petite balloon is inserted into the artery and then inflated to correct any narrowing or remove an obstruction.

Bowman PH, 1999 believes that if your ulcer is large or deep, it may necessitate to be closed by means of plastic surgery. During the procedure skin will be taken from another part of your body to cover the ulcer.

Other treatments;

Pentoxifylline is the treatment of intermittent claudicating. This sort of treatment is introduced by Margolis, DJ. In his book Pentoxifylline in the Treatment of Venous Leg Ulcers during 2000.  Its use in venous leg ulcers was evaluated. Pentoxifylline 800 mg three times a day appears to be a useful adjuvant to compression bandaging for curing venous leg ulcers.

Phillips T, Stanton B, Provan A, Lew R. 1994 proposes, Hypoxic tissues, reperfusion injury, compartment syndrome, crush injury, failing flaps, burns and necrotizing infections have all responded favourably to hyperbaric oxygen. It is used for chronic wounds, particularly diabetic foot infections and leg ulcers caused by arterial insufficiency.

Vacuum-assisted closure is a modern technique using negative pressure, for closing of chronic wounds. The technique suggested by Evans, D. Land, L. 2001, consists in placing open-cell foam dressing into the sore and applying a sub atmospheric pressure. This removes chronic edema, and leads to improved localized blood flow resulting in better formation of granulation tissue. The VAC could be used as an adjunct treatment for persistent, no healing wounds, particularly those that are deep and complicated. (O’Meara SM, 2001)

Surgery
Treating the ulcer by means of surgical treatment is well-known. Other surgical procedures include superficial stripping and excision of varies, subfascial perforating vein interruption, skin grafting and excision, free flap coverage and excision.

Skin grafts
The author Falanga V, Eaglstein WH 1993, states that, ‘Pinch grafts may be performed as an outpatient method in patients with minor ulcers. Small punch biopsies are taken from the patient’s thigh and positioned dermal side down on the ulcer bed. For large ulcers split thickness graft is used. The graft may be meshed to keep away from building-up of exudates beneath it. This technique requires anaesthesia and has the drawback of creating a new donor site ulcer.

Methods used in wound closure

Ridker, PM.. 2000 suggests in his theory that cultured keratinocyte allograft could be grown in advance, and stored. They grant speedy coverage of wounds. Keratinocyte allograft signifies “off-the-shelf” skin replacements which avoid both the call for a patient donor site and the postponement required for autologous keratinocyte culture. Khachemoune A, Bello YM, Phillips TJ. Factors revealed that; the chief action of keratinocyte allograft is cytokine-mediated. This allograft is used as adjunct treatment for chosen chronic leg ulcers, but they are not yet commercially accessible.

Other methods of wound closure comprise infrared UV, laser irradiation and low energy, ultrasonography, hydrotherapy, and electrical stimulation. It further includes Constant tension approximation and warming therapy with heat bandages.

;

Prevention
Things you can do to prevent leg ulcer:

Stop smoking.
Lose weight if you are overweight.
Eat more fruit and vegetables and reduce the amount of fat in your diet. This would help to reduce your blood cholesterol levels.
Walk or exercise for at least 30 minutes each day. This will improve the blood circulation in your legs.
Keep the skin on your legs and feet clean and dry. If you use a soap to wash with, make sure it is mild.
Take excellent care of your feet. Wear comfortable, well-fitting shoes and socks. If you hurt your feet or toes take special care to keep the injury clean and dressed.
Trim your toenails often.
Avoid extremes of temperature on your feet and legs, such as hot baths or going out in the snow. Legs and feet should be kept warm.
Avoid sitting with your legs crossed as this can stop blood circulating properly.
Walk about from time to time if you can.
Inspecting your feet and skin is very vital, particularly if you have diabetes. Spotting and treating leg or foot sores early can prevent the sore from developing into an ulcer.

Management
The writer Sarkar PK. Ballantyne 2000 proposed in his book that there are several new wound dressings, topical products, and skin equivalents made accessible. It is essential to adapt wound care plan to the etiology of the ulcer. Cost-effective methods are strongly recommended for long term treatment plans.

Venous ulcer management
Explained by Boulton 1996 that in the absence of apparent wound infection, antibiotics seem to lack effectiveness in treating venous ulcers. Even though acetic acid, povidone-iodine, sodium hypochlorite, and hydrogen peroxide have been shown to be lethal to cultured fibroblasts, they are helpful and able to make use of. Moistened saline gauzes might be suitable for early management of all types of leg ulcers but moisture retentive dressings are preferred. The latter help relieve pain and reduce the regularity of dressing change.  They also are more cost-effective.

According to Margolis DJ, Berlin JA, Strom B. 1999, the healing rate of venous ulcer depends on the initial size of the sore, but 65-70% of it heals within six months. The recurrence rate of healed venous ulcers is as high as 40%.  Surgery to correct apparent venous incompetence, as well as the ligation of incompetent perforating veins may be positive, healing, and curative and may prevent recurrence. Venous surgery should be performed for patients who are unsuccessful in responding to conservative treatment measures and who are adherent to medical management.

Arterial ulcer management
The core treatment of arterial leg ulcers is surgical. The aim is to bring back blood supply to compromised limbs. An optimal control of related predisposing factors, such as hyperlipidemia, diabetes, and hypertension, as well as smoking cessation must be included in the management plan. (Eckman ME, 1995)

Neuropathic ulcer management
The objective of wound dressings is to grant a warm, moist environment that is safe and free from external contamination. Saline wet-to-dry dressings and numerous types of commercially accessible occlusive dressings (e.g.; alginates, foams, and films) are highly of use. All dressings and additional wound care products are only adjuncts to careful local treatment procedures, including lessening of pressure, sharp debridement of injured tissues and control of infection.

Restoration of blood supply, handling of any active infection and protection of the ulcerated areas must be an important part of the management. After absolute healing of the wound, patients must be fitted with footwear designed to reduce trauma and guard bony prominences.

Conclusion
Leg ulcers are very widespread and physicians should be well-known with the common methods used for their diagnosis, analysis and management. Abnormal leg ulcers need more detailed tests. Surgical repair techniques and several skin-substitutes are accessible for optimum management. A wound-healing specialist should be consulted for unusual and difficult to heal leg ulcers. (Mahabir RC, 2001)

References

Bowman PH, Hogan DJ. Leg ulcers: a common problem with sometimes uncommon etiologist. Geriatrics. 1999 Mar; 54(3):43, 47-8, 50 passim.
Phillips T, Stanton B, Provan A, Lew R. A study of the impact of leg ulcers on quality of life: Financial, social, and psychological implications. J Am Acad Dermatol 1994; 31:49-53.
Ridker, PM. Inherited risk factors for venous thromboembolism: implications for clinical practice. Clin Cornerstone. 2000; 2(4):1-14.
Falanga V, Eaglstein WH. The “trap” hypothesis of venous ulceration. Lancet. 341(8851):1006-1008, April 17, 1993
Sarkar PK. Ballantyne S. Management of leg ulcers. Postgraduate Medical Journal. 76(901):674-82, 2000 Nov.
Boulton A. The pathogenesis of diabetic foot problems: An overview. Diab Med 1996; 13(Suppl 1):812-6.
American Diabetes Association. Consensus Development Conference on diabetic foot wound care. Diabetes Care. 1999; 22:1354-1360.
Goldstein DR. Vogel KM. Mureebe L. Kerstein MD. Differential diagnosis: assessment of the lower-extremity ulcer — is it arterial, venous, neuropathic? Wounds-A Compendium of Clinical Research & Practice, 10(4):125-31, 1998 Jul-Aug.
Muha J. Local wound care in diabetic foot complications: aggressive risk management and ulcer treatment to avoid amputation. Postgrad Med 1999;106(1):97-102
Albrant D H. Management of Foot Ulcers in Patients with Diabetes J Am Pharm Assoc 40(4):467-474, 2000.
Armstrong DG. Lavery LA. Vela SA. Quebedeaux TL. Fleischli JG. Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration. Archives of Internal Medicine. 158(3):289-92, 1998 Feb 9.
Wunderlich RP. Armstrong DG. Husain K. Lavery LA. Defining loss of protective sensation in the diabetic foot. Advances in Wound Care. 11(3):123-8, 1998 May-Jun.
Smieja M, Hunt DL, Edelman D, Etchells E, Cornuz J, Simel DL. Clinical examination for the detection of protective sensation in the feet of diabetic patients. International Cooperative Group for Clinical Examination Research. J Gen Intern Med 1999; 14:418-24.
Maessen-Visch MB, Hamulyak K, Tazelaar DJ, Crombag NH, Neumann HA. The prevalence of factor V Leiden mutation in patients with leg ulcers and venous insufficiency. Archives of Dermatology. 135(1):41-44, January1999.
Tyrrell MR, Wolfe JHN. Critical leg ischaemia: an appraisal of clinical definitions. Br J Surg 1993; 80: 177-80.
London N J. Donnelly R. Ulcerated lower limb. BMJ. 320(7249):1589-1591, June 10, 2000.
Caputo GM, Cavanaugh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med. 1995;332:854-860.
Reiber GE. The epidemiology of diabetic foot problems. Diabic Med 1996; 13:S6-11.
Sibbald RG, Williamson D, Falanga V, Cherry GW. Venous leg ulcers. In Krasner DL, Rodeheaver GT, Sibbald RG (eds). Chronic Wound Care: A clinical Source Book for Healthcare Professionals, Third Edition. Wayne, PA: HMP Communications, 2001:483-494.
O’Meara SM, Cullum NA, Majid M, Sheldon TA. Systematic review of antimicrobial agents used for chronic wounds. Br J Surg. 2001 Jan;88(1):4-21.
Eckman ME, Greenfield S, Mackey WC, et al. Foot infections in diabetic patients. Decision and cost-effectiveness analyses. JAMA. 1995;273:712-20
Sonmezoglu K, Sonmezoglu M, Halac M, Akgun I, Turkmen C, Onsel C, Kanmaz B, Solanki K, Britton KE, Uslu I. Usefulness of (99m)Tc-Ciprofloxacin (Infecton) Scan in Diagnosis of Chronic Orthopedic Infections: Comparative Study with (99m)Tc-HMPAO Leukocyte Scintigraphy. J Nucl Med 2001 Apr;42(4):567-574
Mahabir RC, Taylor CD, Benny WB, Dutz JP, Snelling CF. Necrotizing Cutaneous Cryoglobulinemic Vasculopathy. Plastic & Reconstructive Surgery. 107(5):1221-1224, April 15, 2001.
Khachemoune A, Phillips TJ. Cost effectiveness in wound care. In Krasner DL, Rodeheaver GT, Sibbald RG (eds). Chronic Wound Care: A clinical Source Book for Healthcare Professionals, Third Edition. Wayne, PA: HMP Communications, 2001:191-198.
Angle, N. Bergan, JJ. Chronic venous ulcer. BMJ. 314(7086):1019-1023, April 5, 1997.
26.  Margolis DJ, Berlin JA, Strom B. Risk factors associated with the failure of a venous ulcer to heal. Arch Dermatol 1999;135:920-6.

27.  Khachemoune A, Bello YM, Phillips TJ. Factors that influence healing in chronic venous ulcers treated with Cryopreserved Human Epidermal Cultures. Dermatol Surg. (In-press).

28.  Evans, D. Land, L. Topical negative pressure for treating chronic wounds. Cochrane Wounds Group. Issue 1. 2001. Date of Most Recent Update: 28-11-2000.

29.  Margolis, DJ. Pentoxifylline in the Treatment of Venous Leg Ulcers. Arch Dermatol. 136(9):1142-1143, September 2000.