Ayurvedic management of Non healing varicose ulcer - A case study

Getting Ready for Wound Certification: Assessing and Managing Lower Extremity Venous Disease.

Critical issues in preventing post-thrombotic re-ulceration

1. Co-chaired this panel2. University of South Florida, Tampa, FL3. Healthpoint Ltd., Fort Worth, TX4. University of California, San Francisco, CA5. University of Texas Medical Branch, Galveston, TX6. University of Cardiff, Cardiff, Wales, UK7. University of Pennsylvania, Philadelphia, PA8. Private practice, Warren, PA9. Private practice, Tamarac, FL10. University of Pittsburgh, Pittsburgh, PA11. St. Louis University, St. Louis, MO, and12. Washington University, St. Louis, MO

The definition of the venous ulcer

Molecular characterization of post-thrombotic syndrome

Venous leg ulcers affect up to 3% of people aged 65 years and older, present significant pain and suffering, and are associated with long episodes of health care. These chronic wounds recur at rates of up to 69%. A double blind randomized controlled trial was conducted in a home nursing setting in Victoria, Australia to compare the effectiveness of a 23 to 32 mm Hg (moderate) and a 34 to 46 mm Hg (high) compression stocking treatment on venous ulcer recurrence. Participants (n = 100) were monitored for 26 weeks. Study wound recurrence was low (11.8%), and the average time to recurrence was 77.91 days. Adherence to treatment was low (44%) with nonadherence significantly higher in the high-compression stocking group, χ(2)(1) = 8.827, P = .003. Regression modeling found that adherence to treatment significantly predicted study wound recurrence, Wald(1) = 7.917, P = .005. Estimated hazard ratios showed that participants who did not adhere were 9 times more likely to have their wound recur. Risk of recurrence was 3 times greater for those randomized to moderate compression when compared with the high-compression stocking. Implementing strategies that optimize adherence to compression will reduce ulcer recurrence. Once this has been realized, the potential to adhere to high-compression treatment would further reduce the risk of recurrence.

Leg and foot ulcers are symptoms of very different diseases. The aim of this paper is to demonstrate the differential diagnosis of leg ulcers. The majority of leg ulcers occur in the lower leg or foot. In non-venous ulcers the localization in the foot area is more frequent. The most frequent underlying disease is chronic venous disease. In 354 leg ulcers, Koerber found 75.25% venous leg ulcers, 3.66% arterial leg ulcers, 14.66% ulcers of mixed venous and arterial origin and 13.5% vasculitic ulcers. In the Swedish population of Skaraborg, Nelzen found a venous origin in 54% of the ulcer patients. Each leg ulcer needs a clinical and anamnestic evaluation. Duplex ultrasound is the basic diagnostic tool to exclude vascular anomalies especially chronic venous and arterial occlusive disease. Skin biopsies help to find a correct diagnosis in unclear or non-healing cases. In conclusion, chronic venous disease is the most frequent cause of leg ulcerations. Because 25% of the population have varicose veins or other chronic venous disease the coincidence of pathological venous findings and ulceration is very frequent even in non-venous ulcerations. Leg ulcers without the symptoms of chronic venous disease should be considered as non-venous.

Venous leg ulcers represent the worst extreme within the spectrum of chronic venous disease. Affecting up to 3% of the adult population, this typically chronic, recurring condition significantly impairs quality of life, and its treatment places a heavy financial burden upon healthcare systems. The current mainstay of treatment for venous leg ulcers is compression therapy, which has been shown to enhance ulcer healing rates. Open surgery on the veins in the leg has been shown to reduce ulcer recurrence rates, but it is an unpopular option and many patients are unsuitable. The efficacy of the newer, minimally-invasive endovenous thermal techniques has been established in uncomplicated superficial venous disease, and these techniques are now beginning to be used in the management of venous ulceration, though the evidence for this treatment is currently unclear. It is hypothesised that, when used with compression, ablation may further reduce pressures in the leg veins, resulting in improved rates of healing. Furthermore, since long-term patient concordance with compression is relatively poor, it may prove more popular, effective and cost-effective to provide a single intervention to reduce recurrence, rather than life-long treatment with compression. To determine the effects of superficial endovenous thermal ablation on the healing, recurrence and quality of life of people with active or healed venous ulcers. In August 2013 we searched Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions on the language of publication but there was a date restriction based on the fact that superficial endovenous thermal ablation is a comparatively new medical technology. Randomised clinical trials comparing endovenous thermal ablative techniques with compression therapy alone for venous leg ulcers were eligible for inclusion. Trials had to report on at least one objective measure of ulcer healing (primary outcome) such as proportion of ulcers healed at a given time point, time to complete healing, change in ulcer size, proportion of ulcers recurring over a given time period, or at a specific point, and ulcer-free days. Secondary outcomes sought included patient-reported quality of life, economic data and adverse events. Details of potentially eligible studies were extracted and summarised using a data extraction table. Data extraction and validity assessment were performed independently by two review authors, and any disagreements resolved by consensus or by arbitration of a third review author. No eligible randomised controlled trials were identified. There is an absence of evidence regarding the effects of superficial endovenous thermal ablation on ulcer healing, recurrence or quality of life of people with venous leg ulcer disease. The review identified no randomised controlled trials on the effects on ulcer healing, recurrence or quality of life, of superficial endovenous thermal ablation in people with active or healed venous leg ulcers. Adequately-powered, high quality randomised controlled trials comparing endovenous thermal ablative interventions with compression therapy are urgently required to explore this new treatment strategy. These should measure and report outcomes that include time to ulcer healing, ulcer recurrence, quality of life and cost-effectiveness.

A venous leg ulcer (VLU) has a significant negative impact on quality of life. Prevention of a VLU is not yet imbedded in clinical practice because risk factors for developing a first VLU are not well known. To explore further the progression of chronic venous disease (CVD) into a first VLU from the patient's perspective. A qualitative study using semistructured interviews was conducted among male and female patients with a VLU. Patients from primary and secondary care, under and over 50 years of age, and with first and recurrent VLUs were included. The interviews were transcribed and analysed using a narrative approach to a thematic analysis. Transcripts were organized in chronological order and an iterative process was used to code the transcripts. Four key themes and the connections made between them emerged from the 11 narratives on the progression of CVD towards a first VLU: 'comorbidity', 'mobility', 'work and lifestyle' and 'acknowledgment of CVD'. Comorbidity was linked to reduced mobility and late acknowledgment of CVD. Comorbidity also affected work and lifestyle and vice versa. Work and lifestyle affected mobility and was linked to the acknowledgment of CVD. A reduction in mobility as a result of comorbidity and work and lifestyle occurred before the VLU developed. Patients did not recognize symptoms of CVD and did not acknowledge the chronicity of CVD. Healthcare professionals should be aware of reductions in mobility and the knowledge deficit in patients with CVD. What's already known about this topic? Not all patients with chronic venous disease (CVD) develop a venous leg ulcer (VLU). A patient's quality of life decreases significantly when a VLU develops. Risk factors for the development of a first VLU in patients with CVD are not well known, unlike risk factors for other chronic wounds like diabetic foot ulcer and pressure ulcers. What does this study add? The patient's narrative towards the development of a first VLU, a series of events. Insight into the events (comorbidity, mobility, work and lifestyle) that patients themselves link to the development of a VLU. Insight into the patients' acknowledgment of CVD in the progression of CVD towards a first VLU. What are the clinical implications of this work? More awareness is needed of CVD symptoms among patients and healthcare providers, as well as more awareness for prevention of a VLU in clinical practice. New insights (for further studies) are needed into the concept of mobility and the development of a VLU. Improved patient education and follow-up are needed for patients with CVD.

Venous leg ulceration is a recurrent, chronic, disabling condition. It affects up to one in 100 people at some time in their lives. Standard treatments are simple dressings and compression bandages or stockings. Sometimes, despite treatment, ulcers remain open for months or years. Sometimes skin grafts are used to stimulate healing. These may be taken, or grown into a dressing, from the patient's own uninjured skin (autografts), or applied as a sheet of bioengineered skin grown from donor cells (allograft). Preserved skin from other animals, such as pigs, has also been used (xenografts). To assess the effect of skin grafts for treating venous leg ulcers. For this update we modified the search strategies and conducted searches of The Cochrane Wounds Group Specialised Register (searched 27 July 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); Ovid MEDLINE (2008 to July Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 26, 2012); Ovid EMBASE (2008 to 2012 Week 29); and EBSCO CINAHL (2008 to 26 July 2012). We did not apply date or language restrictions. Randomised controlled trials (RCTs) of skin grafts in the treatment of venous leg ulcers. Two review authors independently undertook data extraction and assessment of study quality. For this update of the review, we identified one new trial, bringing the total to 17 trials (1034 participants) - all of which were generally at moderate or high risk of bias. In 12 trials participants also received compression bandaging.Eleven trials compared a graft with standard care in which no graft was used. Two of these trials (102 participants) compared a dressing with an autograft; three trials (80 participants) compared frozen allografts with dressings, and two trials (45 participants) compared fresh allografts with dressings. Two trials (345 participants) compared tissue-engineered skin (bilayer artificial skin) with a dressing. In two trials (97 participants) a single-layer dermal replacement was compared with standard care.Six trials compared alternative skin grafting techniques. The first trial (92 participants) compared autografts with frozen allograft, a second (51 participants) compared a pinch graft (autograft) with porcine dermis (xenograft), the third (110 participants) compared growth-arrested human keratinocytes and fibroblasts with placebo, the fourth (10 participants) compared an autograft delivered on porcine pads with an autograft delivered on porcine gelatin microbeads, the fifth trial (92 participants) compared a meshed graft with a cultured keratinocyte autograft, and the sixth trial (50 participants) compared a frozen keratinocyte allograft with a lyophilised (freeze-dried) keratinocyte allografts.Significantly more ulcers healed when treated with bilayer artificial skin than with dressings. There was insufficient evidence from the other trials to determine whether other types of skin grafting increased the healing of venous ulcers. Bilayer artificial skin, used in conjunction with compression bandaging, increases venous ulcer healing compared with a simple dressing plus compression. Further research is needed to assess whether other forms of skin grafts increase ulcer healing.

Chronic venous disease is a circulatory system dysfunction that has the potential to lead to venous leg ulceration. Although research on the influence of specific gene variants on chronic venous disease has been limited, a few studies have reported an association between hemochromatosis and chronic venous disease. However, no studies have looked at the prevalence of lower-limb venous disease and leg ulcers in people with hemochromatosis. This study aimed to review the existing literature for any association between venous disease and hemochromatosis and investigate the prevalence of venous disease and leg ulcers in people with hemochromatosis. Scoping systematic literature review and cross-sectional study surveying people with hemochromatosis. This scoping systematic literature review included nine articles and indicated a link between hemochromatosis and venous disease/leg ulcers, although further studies are needed to support this link. Analysis of survey results from people with hemochromatosis found a 9.2% prevalence of leg ulcers in those with self-reported hemochromatosis, considerably higher than the 1% to 3% expected, suggesting that hemochromatosis gene variants may be associated with the pathogenesis of chronic venous disease and leg ulcers. This is the first known study to complete a review of the literature regarding hemochromatosis and venous leg ulcers and document the association between hemochromatosis and venous disease/leg ulcers. There is a lack of research in this area and hence limited evidence to guide practice.

Chronic venous insufficiency (CVI) is a major cause of recurrent venous leg ulcers (VLUs) and presents treatment difficulties for elderly patients. This case report describes an 88-year-old female with CVI, cardiomyopathy, hypertension, dyslipidemia, and left-sided hemiplegia who presented with a 10-day history of left lower leg tenderness and purple-red discoloration. Examination revealed bilateral varicosities and a stage 4 VLU over the medial malleolus with purulent drainage and surrounding erythema. After 12 days of compression therapy, the ulcer improved to stage 3. However, two months of non-adherence to the treatment led to recurrence with a new stage 2 ulcer. The patient was subsequently initiated into a structured program with demonstrations, written instructions, scheduled reminders, and weekly follow-ups. After 22 days of consistent compression therapy, the ulcer improved to stage 1. This case emphasizes the importance of consistent compression therapy and multifaceted approaches in managing recurrent VLUs.

Venous ulcers are chronic open skin sores, difficult to heal, caused by bad microcirculation in patients with chronic venous insufficiency (CVI) and sustained venous hypertension. In this pilot supplement registry study, the efficacy and safety of oral Centellicum® (Centella Asiatica standardized extract, Horphag Research) 675 mg/day for 3 months as part of the management of venous ulcerations were evaluated. Study endpoints considered measuring the changes in the area of the ulceration and microcirculatory parameters in patients with CVI. 160 subjects with venous ulcers and CVI completed the study: 80 in the Centellicum® group, supplemented with 675 mg Centellicum® per day in addition to the best management treatment (BM) and 80 in the control group with only the BM. The control and treatment groups were comparable for age and sex distribution. Skin resting flux is generally abnormally increased at the peri malleolar region in CVI patients and around ulcerations. Both groups exhibited improvements in microcirculation, skin resting flux (RF) measured with Laser Doppler flowmetry (LDF), transcutaneous PO<inf>2</inf> and PCO<inf>2</inf>. However, the supplementation proved to be more effective than the best management only (P<0.05). After 90 days, the supplement group exhibited a significantly lower number of ulcerations and average ulcer area compared to the control group (P<0.05). In the Centellicum® group, the ulcer area decreased from 2.34±0.3 cm2 to 0.33±0.5 cm2, whereas in the control group, it only decreased from 2.4±0.5 cm2 to 1.61±0.7 cm2. The difference between the two management groups was statistically significant (P<0.021). The rate of completely closed ulcers was 96.2% in the Centellicum® group, significantly higher than the 83.7% healing rate observed in in the control group. Notably, after just one month, 65% (52/80) of ulcers in the Centellicum® group had completely healed, compared to only 18.75% (15/80) in the control group. Ulcer closure was the most critical clinical outcome observed. In venous ulcerations, Centellicum® supplementation in combination with ulcer management, improved microcirculation parameters and ulcer healing rate. Most of the treatments were done at home by the patients or by their tutors. This study indicates a potential role of Centellicum® in venous ulcers and CVI and suggests the need to plan larger and more prolonged healing studies.

A prospective, randomized trial of Unna's boot versus Duoderm CGF hydroactive dressing plus compression in the management of venous leg ulcers

Venous leg ulcers (VLUs) are a common, chronic and recurrent condition associated with considerable morbidity and healthcare burden. In Ayurveda, such non-healing ulcers can be correlated with Sirajanya Dushta Vrana, which results from Doshic vitiation and improper wound care. This case report presents a 31-year-old male patient with a non-healing ulcer over the medial malleolus of the right lower limb associated with chronic venous insufficiency. The patient underwent an integrative Ayurveda treatment protocol including Bahya shodhana (external therapies), Panchakarma procedures such as Basti (medicated enema), Jalauka vacharana (leech therapy) and Shamana Aushadhi (oral medications) over a 45-day period. Complete healing of the ulcer was achieved without adverse effects. The case highlights the potential of Ayurveda based protocols in managing chronic ulcers resistant to conventional treatments.