Cleanse, Dress, and Compress Using Synergistic Products and Procedures: An Algorithmic Approach to the Treatment of Venous Leg Ulcers
Venous ulceration is the most common type of leg ulceration and is a significant clinical problem that affects approximately 1% of the population and 3% of persons older than 80 years of age in Western countries, and the global prevalence of venous leg ulcers (VLUs) is predicted to escalate dramatically as people live longer and with multiple comorbidities.1 It is widely accepted that best evidence-based practice for the management of VLUs is compression therapy. To combat the impact of VLUs on patients’ lives and the economy, a standardized approach to management has been proposed in the authors’ facilities. This approach includes early assessment and diagnosis, adequate wound bed preparation, edema control, and use of specialized topical dressings.
This article presents a 4-patient case series in which a standardized algorithm approach to improve healing rates in patients with VLUs was used. The treatment algorithm included early assessment and diagnosis, wound bed preparation using hypochlorous acid–preserved wound cleanser (HAPWOC; Vashe, Urgo Medical North America) soaks for 10 minutes, a specialized hydroconductive dressing (Drawtex, Urgo Medical North America) for exudate management, and application of a multilayer venous compression bandage with a dual compression system bandage (UrgoK2, Urgo Medical North America) that allows therapeutic pressure to be applied to the wound regardless of the ambulatory status of the patient.
CASE 1 (Figure 1)
The patient was a 69-year-old man with hypertension (controlled with medication) and a history of a cerebrovascular accident, stage 3 chronic kidney disease, and venous insufficiency. The right ankle brachial index (ABI) was 1.44. Left noncompressible arterial vessels with arterial duplex multi waveforms allowed the consideration of compression application. Venous insufficiency was noted. On the right, segmental incompetence was noted in the great saphenous vein (GSV) in addition to an incompetent perforator. On the left, the GSV was incompetent throughout, and the short saphenous vein (SSV) also was incompetent. The wounds had been present for several months. The patient stated that they first appeared when he began scratching his legs. The patient had been hospitalized for 1 week due to cellulitis.
Treatment plan. Sharp debridement was used. HAPWOC-soaked gauze was applied for 5 to 10 minutes. Collagen dressing was applied to the wound base and was covered with a hydroconductive dressing. The wound was wrapped with the multilayer dual compression system bandage. Dressing changes took place 2 times a week for the first 30 days and then weekly. At day 41, treatment was transitioned to a home compression garment.
CASE 2 (Figure 2)
The patient was a 54-year-old man with hypertension (controlled with medication), hyperlipidemia, obesity, anxiety, history of deep vein thromboses with inferior vena cava filter placement, and venous insufficiency. ABIs were as follows: right, 1.66; and left, 1.78 (bilateral noncompressible vessels with triphasic waveforms). Venous insufficiency was noted: Right, common femoral vein incompetent, GSV segmental incompetence, and superficial accessory vein incompetent; and Left, GSV incompetent throughout, short saphenous vein incompetent, and incompetent perforator. The patient underwent radiofrequency ablation of the right and left GSV prior to the beginning of the treatment protocol.
Treatment plan. Sharp debridement was used. HAPWOC-soaked gauze was applied for 5 to 10 minutes, and the wound was covered with a hydroconductive dressing. The wounds were wrapped with the multilayer dual compression system bandage, and dressing changes occurred weekly. On day 63, treatment was transitioned to a home compression garment.
CASE 3 (Figure 3)
The patient was a 53-year-old man with morbid obesity, atrial flutter, hypertension (controlled with medication), stage 3 chronic kidney disease, hyperhomocysteinemia, and venous insufficiency (right: GSV previously ablated, mid-calf perforator; and left: previously ablated, incompetent perforator, and posterior accessory saphenous vein incompetent). ABI was not completed because distal (foot) pulses were palpable.
Treatment plan. Sharp debridement was used. HAPWOC-soaked gauze was applied for 5 to 10 minutes. Collagen dressing was inserted into the wound base and covered with a hydroconductive dressing. The wound was wrapped with the multilayer dual compression system bandage. Weekly dressing changes were implemented; on day 150, treatment was transitioned to a home compression garment.
CASE 4 (Figure 4)
The patient was a 59-year-old woman with morbid obesity, hypertension (controlled with medication), type 2 diabetes, hypercholesterolemia, and venous insufficiency (right: GSV with segmental incompetence; and left: GSV incompetent throughout, and SSV incompetent at the distal end). ABI was not completed because distal (foot) pulses were palpable. The patient underwent radiofreqency ablation of the left GSV prior to beginning the treatment protocol.
Treatment plan. Sharp debridement was used. HAPWOC-soaked gauze was applied for 5 to 10 minutes, and the wound was then covered with a hydroconductive dressing. The wound was subsequently bandaged with a multilayer dual compression bandage for the larger ankle circumference with no problems regarding application or patient compliance. Weekly dressing changes were performed. On day 56, treatment was transitioned to a home compression garment.
RESULTS
Four (4) patients were chosen for this case series. Two (2) had high ABIs, and their arterial wavelengths were bi/triphasic and therefore still suitable for compression. Two (2) other patients did not have any arterial disease and were not deemed suitable for ABI measurement because distal pulses were present to a level that discounted arterial insufficiency in the lower limb. Sequential wound images showed steady progression toward wound size reduction and then healing over the course of the study. The improving condition of the periwound skin was remarkable.
DISCUSSION
Chronic wound management can be complex in patients with various comorbidities because they may experience impaired wound healing. For this reason, it is recommended that a systematic approach to wound care be developed that can be applied consistently to a majority of patients with venous leg ulcer. The patients in this case series received wound care based on a proposed standardized algorithm approach beginning with proper diagnosis, adequate wound bed preparation, use of advanced dressings, and proper compression using newly available technologies. All cases presented showed continued healing with optimal healing rates and increased patient and provider satisfaction in terms of quality of life associated with the use of these products.
More than 80% of chronic wounds have biofilm-related issues,2 and frequent wound cleansing with proven and effective cleansers, such as the HAPWOC product used in the current study, is supported by biofilm removal evidence of such cleansers.3-6 HAPWOC has been shown to be clinically effective, and indeed is recommended in several publications and guidelines.7-10 The hydroconductive dressing is known from previous publications to have an ability to remove microbes and harmful agents, such as matrix metalloproteinases, from the wound site.11-17 The compression bandage has a dual compression system, which has been shown to provide the essential 3 C’s of compression, which are consistency (of correct pressure application without fail), continuity (of therapeutic pressure, day or night, regardless of the mobility status of the patient), and comfort (which drives compliance for bandage-wearing).18-21 Taken together, these key properties working synergistically (in the cleanser, dressing, and compression bandage) lead to wound healing with maximal patient acceptance and minimal complications.
CONCLUSION
The authors chose rather serious venous wounds for testing the new proposed algorithm. Although clinical studies of a larger size are recommended, the consistency of the results seen in these 4 patients show the benefits of the cleanse, dress, and compress algorithm with specialized and appropriate wound care products.
Ms. Greenstein is a certified nurse practitioner, Sanford Health, Fargo, ND. Dr. Tickner is a podiatrist in Hudson, MA. Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMP Global.
This article was not subject to the Wound Management & Prevention peer-review process.
1. Davis AH. The seriousness of chronic venous disease: a review of real-world evidence. Adv Ther. 2019;36(suppl 1):5–12. doi:10.1007/s12325-019-0881-7
2. Attinger C, Wolcott R. Clinically addressing biofilm in chronic wounds. Adv Wound Care (New Rochelle). 2012;1(3):127–132. doi:10.1089/wound.2011.0333
3. Day A, Alkhalil A, Carney BC, Hoffman HN, Moffatt LT, Shupp JW. Disruption of biofilms and neutralization of bacteria using hypochlorous acid solution: an in vivo and in vitro evaluation. Adv Skin Wound Care. 2017;30(12):543–551. doi:10.1097/01.ASW.0000526607.80113.66
4. Harriott MM, Bhindi N, Kassis S, et al. Comparative antimicrobial activity of commercial wound care solutions on bacterial and fungal biofilms. Ann Plast Surg. 2019;83(4):404–410. doi:10.1097/SAP.0000000000001996
5. Robson MC. Treating chronic wounds with hypochlorous acid disrupts biofilm. Wound Manage Prev. 2020;66 (5):8–10.
6. Sakarya S, Gunay N, Karakulak M, Ozturk B, Ertugrul B. Hypochlorous acid: an ideal wound care agent with powerful microbicidal, antibiofilm, and wound healing potency. Wounds. 2014;26(12):342–350.
7. Hiebert JM, Robson MC. The immediate and delayed post-debridement effects on tissue bacterial wound counts of hypochlorous acid versus saline irrigation in chronic wounds. Eplasty. 2016;16:e32.
8. Niezgoda JA, Sordi PJ, Hermans MMHE. Evaluation of Vashe Wound Therapy in the clinical management of patients with chronic wounds. Adv Skin Wound Care. 2010;23(8):352–357. doi:10.1097/01.ASW.0000383198.35815.a2
9. Alberto EC, Cardenas L, Cipolle M, Gallagher KE. Level 1 trauma center experience utilizing negative pressure wound therapy with instillation: hypochlorous acid versus normal saline solution in complex or infected wounds. J Med Sci Clin Res. 2020;8(6):414–420. https://dx.doi.org/10.18535/jmscr/v8i6.79
10. Armstrong DG, Bohn G, Glat P, et al. Expert recommendations for the use of hypochlorous solution: science and clinical application. Ostomy Wound Manage. 2015;61(5):S2–S19.
11.Wolvos T, Livingston, M. Wound fluid management in wound care: the role of a hydroconductive dressing. Wounds. 2013; 25(1):7–14.
12. . Robson MC. Innovations for wound bed preparation: the role of Drawtex hydroconductive dressings. Wounds. 2012;24(9)(suppl):2.
13. 1. Wolvos T. Analysis of wound bed documentation in advanced wound care using Drawtex, a hydroconductive dressing with LevaFiber technology. Wounds. 2012;24(9)(suppl):9–10.
14. Wolcott RD, Cox S. The effects of a hydroconductive dressing on wound biofilm. Wounds. 2012;24(9)(suppl):14–16.
15. Ortiz RT, Moffatt LT, Robson MC, Jordan MH, Shupp JW. In vivo and in vitro evaluation of the properties of Drawtex LevaFiber wound dressing in an infected burn wound model. Wounds. 2012;24(9)(suppl):3–5.
16. Ochs D, Uberti G, Donate GJ, Abercrombie M, Mannari RJ, Payne WG. Evaluation of mechanisms of action of a hydroconductive wound dressing (Drawtex) in chronic wounds. Wounds. 2012;24(9)(suppl):6–8.
17. Wendelken M, Lichtenstein P, DeGroat K, Alvarez OM. Detoxification of venous ulcers with a novel hydroconductive wound dressing that absorbs and transports chronic wound fluid away from the wound. Wounds. 2012;24(9)(suppl):11–13.
18. Hanna R, Bohbot S, Connolly N. A comparison of interface pressures of three compression bandage systems. Br J Nurs. 2008;17(20):S16–S24. doi:10.12968/bjon.2008.17.Sup9.31661
19. Benigni JP, Lazareth I, Parpex P, et al. Efficacy, safety and acceptability of a new two-layer bandage system for venous leg ulcers. J Wound Care. 2007;16(9):385–390. doi:10.12968/jowc.2007.16.9.27866
20. Jünger M, Ladwig A, Bohbot S, Haase H. Comparison of interface pressures of three compression bandaging systems used on healthy volunteers. J Wound Care. 2009;18(11):474–480. doi:10.12968/jowc.2009.18.11.45000
21. Lazareth L, Moffatt C, Dissemond J, et al. Efficacy of two compression systems in the management of VLUs: results of a European RCT. J Wound Care. 2012; 21(11):553–565. doi:10.12968/jowc.2012.21.11.553
