Latest in treatment of lower-extremity ulcers
This is a review article published in The New England Journal of Medicine. Below is a review of the general treatment principles.
Dead skin from the edges of the ulcer should be sharply debrided with a scalpel, scissors, or both down to viable tissue.
Topical iodine is recommended for contaminated ulcers but without evidence of active infection. If the wound is actively infected, treat for Gram-positive organisms initially with topical antibiotics (mupirocin) and, if the infection is more severe, progress to oral antibiotics with dicloxacillin, doxycycline, or clindamycin.
If infection is uncertain, consider a wound biopsy and treat if there are >106 colony-forming units per gram of tissue.
Dry wounds should be treated with a moisture-promoting dressing such as a hydrogel (eg, Aquaform, INTRASITE, GranuGEL, NU-GEL, Purilon, Sterigel). A simple wet to dry dressing is still an excellent option for venous ulcers.
Exudative wounds should be treated with absorptive dressings such as a hydrofiber (eg, AQUACEL, Versiva).
For venous ulcers, use an elastic wrap that has more pressure distally and overlaps the previous wrap by 50%. This also supports reducing the inflammation associated with venous ulcers.
Oral medications that may help speed the healing of venous leg ulcers include pentoxifylline, aspirin, simvastatin, and sulodexide.
This is useful for non-healing vascular ulcers. Consider referral for any non-healing ulcer if healing is slower than 30% for venous ulcers and 50% for diabetic foot ulcers after 4 weeks.
David Rakel MD, FAAFP