A new treatment for the management of a chronic venous leg ulcer
25/05/10 | Infection, Leg ulcers | Sharon Dawn Bateman
This case study highlights the challenges of managing a patient with a hard-to-heal wound and lymphoedema. It explores the use of an advanced wound care treatment together with a holistic approach to care, which has led to a significant improvement in the patient’s quality of life.
Many clinicians will encounter patients who present with chronic, static and difficult-to-heal wounds. Chronic venous disease with ulceration of the lower limb is a common problem that results in significant morbidity, is expensive to manage clinically and adversely impacts upon the patient's quality of life and wound care experience . It is essential that these patients are referred promptly to specialist wound care clinicians, who can implement evidence-based assessment and treatment plans, ensuring that the patient receives a high standard of quality-focused care. At times this will involve using new treatments and advanced wound care products.
Mrs D is a young woman aged 42 whose quality of life had been increasingly compromised over the past three years by a chronic venous leg ulcer. Treatment was complicated by gross lymphoedema, hypertension, reduced mobility and poor mental health requiring long-term antidepressant medication.
Mrs D first developed a venous ulcer in 2007 on her lower left anterior tibial region following a traumatic fall involving contact with the sharp edge of a piece of furniture. The resulting haematoma quickly developed into a small open ulcer, which continued to expand and deepen over the subsequent three years, with occasional intermittent minor improvements in wound size and depth. Although various dressings, therapies and compression bandages had been tried, there had been only small improvements with the ulcer always reverting back to its original static non-healing status. From time to time, the patient developed systemic infections that required intravenous antibiotic therapy, which was administered either in hospital or the local infection control/travel medicine clinic. The wound was associated with severe chronic pain and discomfort as well as a lingering background malodour, which caused the patient some embarrassment.
Mrs D lives with her husband, who supports her in maintaining as normal a quality of life as is practically possible, despite regular clinic visits and intermittent hospital admissions for treatment and physiotherapy. However, the chronic nature of her ulcer had resulted in Mrs D becoming depressed and even expressing a recurring wish for the leg to be amputated.
Mrs D was referred by her local general practitioner within the infection control/travel medicine department at the local university teaching hospital. On initial assessment the wound bed appeared sloughy with a central necrotic region and moderate maceration around the wound margin. The wound measured 9 x 4 x 0.4cm with a macerated 4cm periwound border [Fig 1]. The ulcerative region revealed small, visible areas of underlying healthy granular tissue. Microbiology results indicated that the wound bed was locally infected with the presence of Staphylococcus aureus, a common pathogen found in the infected chronic wound .
Fig 1 – The wound on presentation. Wound dimensions 9cm x 4cm x 0.4cm; necrotic, sloughy, high level of exudate
The wound was producing moderate levels of medium viscosity exudate and the surrounding skin appeared fragile, macerated and inflamed. Using a numerical 0-10 pain scale, where 0 is no pain and 10 is the most extreme pain imaginable , the patient's average pain score was 6/10 rising to 8/10 at dressing changes. This was despite regular opoid (morphine) analgesia.
- 42 year old patient presented with a chronic venous leg ulcer, complicated by gross lymphoedema
- The wound was associated with severe chronic pain and background malodour
- The patient’s quality of life was severely impaired