Addressing the Pain: Treating Venous Insufficiency Ulcers with Soft Silicone Dressing

    Venous insufficiency ulcers in the lower extremities arise as a late manifestation of venous system incompetence.

These ulcers are the most common vascular disorder and account for 80% to 90% of all lower extremity ulcers.¹ Often, patients also have edema of the lower legs that further compromises oxygen and nutrition to the skin. The patient commonly presents with a long history of recurring problems such as lower leg edema, heaviness, blister formation, and slower healing from minor injuries that become worse with each episode. Traditional treatment has centered on reducing edema with limb elevation, compression wraps, stockings, or Unna boots. Understanding the nature of venous ulcers and the way in which wounds heal has enabled clinicians to tailor treatment specifically to each patient rather than to take a cookie-cutter approach. Most often, treatment now involves both compression and local wound care designed to reduce inflammation, resolve infection, and heal the ulcer.²

    Compression is essential and can be accomplished in various ways as stated above. Staff at our center prefer to utilize three- or four-layer compression wraps such as Profore and Profore Lite (Smith & Nephew, Largo, Fla.). The decision to use three or four layers of compression is dependent upon the ankle/brachial index (ABI). The three-layer wrap is utilized if the ABI is 0.5 to 0.8 and the four-layer wrap is utilized if the ABI is 0.8 to 1.0. Consideration is also taken if the patient has diabetes and small vessel disease. Other compression products include Surepress and Setopress (ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ). Unna boots (Gelocast, BSN-Jobst, Charlotte, NC) are used at some centers; however, they have been found to be less effective than layered compression wraps.

    Patients with venous ulcers are generally seen one to two times weekly at our clinic. Wound assessment, sharp debridement, and tissue cultures are routinely performed. Local wound care depends upon wound presentation. If positive cultures are obtained, the patient is placed on appropriate topical, and/or oral/IV antibiotics. Topical antibiotics most often used include Silvadene (Medline Industries, Inc., Mundelein, Ill.) and Bactroban (SmithKline Beecham Pharmaceuticals, Philadelphia, Pa.). A silver-coated dressing such as Acticoat, Acticoat 7 (Smith & Nephew) or Silvasorb (Medline Industries) may be applied to the wound bed to reduce bacterial load. Elidel (Novartis Pharmaceuticals Corp., East Hanover, NJ) is often applied to intact periwound tissue to reduce inflammation before compression wraps are placed.

    Venous ulcers historically have been thought to be comparatively pain free. We now know that a significant number of patients with venous ulcers have pain (either constant or related to dressing changes) that will impact their quality of life.³ Frustration and interference with normal daily activities are frequent patient complaints.⁴

Case Study

    Our center, which is located in a rural farming area, averages 270 to 285 patient visits per month, 56% of which are for patients older than 65 years, 23% of whom present with venous ulcers. Ms. O, an 82-year-old Caucasian woman, is typical of the venous ulcer patients we see. She presented on November 21, 2003 with a 2-to 3-month history of lower leg edema, weeping, and open wounds (see Figures 1 and 2). Multiple wounds that measured from 3.9 cm x 2.3 cm x 0.1 cm to 0.5 cm x 0.5 cm x 0.1 cm also were noted. Lower leg edema measurements were 35.5 cm (right leg) and 36.5 cm (left leg) on admission. Ms. O also had a history of chronic anemia, chronic renal insufficiency, and chronic obstructive pulmonary disease. Because of her diffuse wounds, she experienced pain with movement and wound dressing changes. She rated her pain level as 5 on a scale of 1 to 10 constantly and as a 10 with dressing changes. Various products had been tried with limited success.

    Ms. O’s clinicians became aware that Mepilex Transfer (Mölnlycke Health Care, Newtown, Pa.) had been used successfully in treating patients with Epidermolysis Bullosa. On March 11, the product was applied to Ms. O’s wounds to see if it would reduce her pain level. The dressing was cut into strips and applied vertically to her legs, followed by Profore Lite (Smith & Nephew) compression wraps. Ms. O was pleased with the cooling sensation achieved by the Safetac® silicone foam as well as the fact that the dressing stayed in place without the need for tape or gauze wrapping. Periwound maceration also was reduced. At her next visit, March 15, she begged us to continue with this product. She rated her pain as 0 with movement and minimal with dressing changes.

    Ms. O’s dressings were changed twice weekly throughout her treatment protocol. By March 22, the improvement in her wounds was dramatic (see Figure 3). She had no pain and the original wounds were healed. However, as is the nature of venous insufficiency, two new wounds had developed that measured 2.5 cm x 2.0 cm x 0.2 cm and 2.5 cm x 2.4 cm x 0.4 cm. In addition, Ms. O continued to have difficulty with lower leg and foot edema despite compression so a compression pump was added to her plan of care to be utilized 2 hours per day. Lower leg edema varied from 25.5 cm to a high of 35.5 cm. The compression pump did not make a big difference, however, due to her underlying health condition and use was discontinued after about 1 month.

Conclusion

    The soft silicone transfer dressing significantly reduced Ms. O’s pain and provided excellent vertical wicking properties that reduced periwound maceration. Time to healing time for new wounds was less than noted with other treatment modalities. Because of decreased discomfort with dressing changes, Ms. O was less reluctant to continue follow-up visits. This product has since been utilized when caring for other patients with venous ulcers and similar responses have been noted.

Addressing the Pain is made possible through the support of Mölnlycke Health Care, Newtown, Pa.

1. McCulloch JM, Kloth LC, Feedar JA. Treatment of wounds caused by vascular insufficiency. In: Wound Healing Alternatives in Management. Philadelphia, Pa.: F. A. Davis Company;1995:213-221.

2. Larson-Lohr V. Problem wound management: CVI and venous ulcers. Workshop manual for Problem Wound Management Symposium. Elsinor Medical Consultants;2003.

3. Ryan S, Eager C, Sibbald RG. Venous leg ulcer pain. Ostomy Wound Manage. 2003; 49(4Asuppl):16–23.

4. Krasner D. Pain venous ulcers: themes and stories about their impact on quality of life. Ostomy Wound Manage. 1998;44(9):38–39.