Venous Leg Ulcers: A Historical Perspective and Future Directions in Care
Venous leg ulcers (VLUs) are the most common type of ambulatory ulcers, affecting 1% to 2% of the population, with between 500,000 and 2 million new cases diagnosed each year.1,2 These chronic wounds arise due to venous reflux, a condition in which the valves in the veins malfunction, causing blood to pool in the legs. The result is increased venous pressure, swelling, and eventually, the breakdown of the skin, leading to ulceration.
VLUs are not just physically debilitating; they also take a significant psychological toll on patients, who may isolate themselves due to the pain. Drainage, including associated odor, and stigma associated with the condition can also have a profound impact. Treating VLUs is not just about healing the wound—it’s about addressing the broader physical and psychological needs of the patient. With a notoriously high recurrence rate that complicates treatment, VLUs present a long-term challenge for both patients and healthcare providers.3
Historically, VLUs are understood as a consequence of venous reflux. In healthy veins, one-way valves prevent blood from flowing backward, and the calf muscle acts as a pump to push blood back to the heart. However, when the valves fail, blood flows in reverse, causing swelling and increasing pressure in the veins. This venous hypertension leads to tissue damage and ulceration.
Development of Wound Care and Advanced Treatment Options
Early treatment of VLUs focused on reducing edema and supporting venous return, with compression therapy being a widely used method. Compression assists in managing swelling and can improve the circulatory process, but it does not address the root cause of the reflux, leaving patients vulnerable to a high likelihood of recurrence.
Over time, topical dressings were introduced to better manage VLUs. Silver dressings, foams, and collagens became common tools for managing the significant exudate that accompanies these ulcers. Silver dressings offered antimicrobial properties, protecting against infection, while foams absorbed excess moisture, keeping the wound environment conducive to healing. Collagen dressings provided structural support for new tissue growth, helping the wound bed to heal. These topical dressings helped manage symptoms, but they were often used in combination with more advanced therapies.
Surgical interventions are also a critical intervention in managing VLUs that do not respond to conservative treatments. Skin grafts, particularly split-thickness skin grafts, were once the standard for covering large, nonhealing ulcers. However, recently amniotic membranes and other advanced materials have been used to promote faster and more efficient healing.4 These grafts help to push chronic wounds into an acute healing phase, often following debridement, and when combined with compression therapy, they significantly enhance the healing process improving outcomes by supporting tissue regeneration while managing underlying venous issues.
Radiofrequency ablation (RFA) is another contemporary procedure addressing the root cause of VLUs, typically performed by interventional radiologists or vascular surgeons and involving the sealing of dysfunctional veins to prevent venous reflux. The physician inserts a catheter into the vein, applying radiofrequency energy to close the vein, preventing blood from flowing backward, which reduces venous pressure and swelling. There is some disagreement surrounding RFA and whether one should perform it before or after wound healing.5 Some argue that treating the underlying venous problem early creates a better healing environment, while others believe it’s better to wait until the wound has closed to avoid further complications. However, RFA has proven effective in reducing recurrence rates and improving long-term outcomes for patients with chronic VLUs.5
One of the critical components of VLU management is debridement, which helps to remove dead or infected tissue to promote healing. Traditional surgical debridement using a blade is effective, but pain management can be challenging, even for patients with diabetes-related neuropathy. Recent advances in enzymatic debridement are transforming the process. Bromelain, an enzyme derived from pineapples, may offer a gentler, yet effective, alternative to mechanical debridement.6 Bromelain-based debridement requires fewer applications (often 8 or fewer) than the currently available enzymatic debridement therapies and is less painful for patients than surgical or other mechanical methods, making it a valuable adjunct therapy. This method allows for faster removal of necrotic tissue, shortening the healing time and improving patient outcomes.6
Current Challenges with Existing Treatment Modalities
While compression therapy continues to be the cornerstone of VLU management with compression garments applying external pressure to the legs, reducing swelling and supporting venous circulation, it is not suitable for patients with arterial insufficiency, as compression can worsen ischemia and lead to further complications. This has led to ongoing debates within the medical community about the best approach for those patients with mixed arterial and venous disease.7 Despite these challenges, compression remains a vital part of the treatment process for most VLU patients, helping to reduce swelling and facilitate wound closure.
Studies show that up to 70% of VLUs reappear within months or years of healing.8 This recurrence is often due to the ongoing nature of the venous reflux and the difficulty in maintaining long-term compression therapy. Even after a wound heals, patients are left with underlying venous insufficiency, making it essential to continue wearing compression garments to prevent future ulcers. Advanced wound care products, when combined with compression, offer some hope for reducing recurrence rates, but the challenge of long-term management remains.
The Future of Treatment
The future of VLU treatment lies in the combination of advanced products like skin grafts, amniotic membranes, and other bioengineered materials. These products not only cover the wound but also promote tissue regeneration and healing at a cellular level. As research continues into these advanced therapies, they hold the promise of reducing the chronic recurrence rates of VLUs. Combined with early interventions like RFA and the use of compression, in my estimation, these products represent the next frontier in VLU care, potentially providing patients with better long-term outcomes and improved quality of life.6
Enzymatic debridement, particularly with bromelain, is emerging as a key adjunct therapy in modern VLU management. Due to their rapid efficacy, bromelain-based products, when paired with compression therapy, prepare the wound for further treatment, such as skin grafts or advanced dressings, resulting in faster overall time to healing.6
Venous leg ulcer treatment has evolved, but is not without its challenges. While common, VLUs remain a complex condition, with high recurrence rates and significant physical and psychological impacts. As the field of wound care continues to advance, new therapies including novel enzymatic debridement and skin grafts offer hope for faster healing and better outcomes.9 The future of VLU management will depend on continued innovation and a holistic approach to patient care.
Robert J. Snyder, DPM, MSc, MBA, CWSP, FFPM RCPS, is Dean, Professor, Director of Clinical Research and Fellowship Director in Wound Care and Research at Barry University School of Podiatric Medicine. He is certified in foot and ankle surgery by the American Board of Podiatric Surgery and is also a board-certified wound specialist. Dr. Snyder is past-president of the Association for the Advancement of Wound Care and past-president of the American Board of Wound Management. Dr. Snyder serves as the Associate Editor for JAPMA and on the editorial advisory boards of Ostomy Wound Management, Wounds and as a periodic reviewer for the Lancet and NEJM.
References
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2. Agency for Healthcare Research and Quality. Chronic venous ulcers: a comparative effectiveness review of treatment modalities. Available at https://shorturl.at/4kaSv . Published March 5, 2012. Accessed Dec. 5, 2024.
3. He B, Shi J, Li L, et al. Prevention strategies for the recurrence of venous leg ulcers: A scoping review. Int Wound J. 2024;21(3):e14759. doi:10.1111/iwj.14759
4. Heydari P, Mojahedi M, Javaherchi P, Sharifi M, Kharazi AZ. Advances and impact of human amniotic membrane and human amniotic-based materials in wound healing application. Int J Biol Macromol. 2024;281(Pt 4):136596. doi:10.1016/j.ijbiomac.2024.136596
5. Sermsathanasawadi N, Jieamprasertbun J, Pruekprasert K, et al. Factors that influence venous leg ulcer healing and recurrence rate after endovenous radiofrequency ablation of incompetent saphenous vein. J Vasc Surg Venous Lymphat Disord. 2020;8(3):452-457. doi:10.1016/j.jvsv.2019.11.003
6. Shoham Y, Krieger Y, Tamir E, Silberstein E, Bogdanov-Berezovsky A, Haik J, Rosenberg L. Bromelain-based enzymatic debridement of chronic wounds: A preliminary report. Int Wound J. 2018 Oct;15(5):769-775. doi: 10.1111/iwj.12925. Epub 2018 Apr 25. PMID: 29696785; PMCID: PMC7950085.
7. Harding JP, Hedayati N. Challenges of treating mixed arterial-venous disease of lower extremities. J Cardiovasc Surg (Torino). 2021 Oct;62(5):435-446. doi: 10.23736/S0021-9509.21.11901-9. Epub 2021 Apr 21. PMID: 33881286.
8. Finlayson KJ, Parker CN, Miller C, et al. Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool. Int Wound J. 2018;15(5):686-694. doi:10.1111/iwj.12911
9. Shoham Y, Gasteratos K, Singer AJ, Krieger Y, Silberstein E, Goverman J. Bromelain-based enzymatic burn debridement: A systematic review of clinical studies on patient safety, efficacy and long-term outcomes. Int Wound J. 2023 Dec;20(10):4364-4383. doi: 10.1111/iwj.14308. Epub 2023 Jul 16. PMID: 37455553; PMCID: PMC10681521.
