SIGN Guideline 120: Management of chronic venous leg ulcers

Summary of recommendations

All patients with chronic venous leg ulcer should have an ABPI performed prior to treatment.

D Measurement of ankle brachial pressure index should be performed by appropriately trained practitioners who should endeavour to maintain their skills.

D Compression therapy may be safely used in leg ulcer patients with ABPI≥0.8.

D Patients with an ABPI of <0.8 should be referred for a specialist vascular assessment.

Patients with an abnormal ABPI should have their cardiovascular risk factors treated according to the SIGN guideline on management of peripheral arterial disease (SIGN 89).

3.2.2 Pulse oximetry

Pulse oximetry is not routinely recommended, but may be a useful adjunctive investigative tool in specialist leg ulcer clinics.

3.3.1 Clinical assessment

C The surface area of the ulcer should be measured serially over time.

The ulcer edge often gives a good indication of progress and should be carefully documented (eg shallow, epithelialising, punched out).

The base of the ulcer should be described (eg granulating, sloughy).

The position of the ulcer(s), medial, lateral, anterior, posterior, or a combination, should be clearly described.

3.3.2 Biopsy

D Patients with a non-healing or atypical leg ulcer should be referred for consideration of biopsy.

3.3.3 Bacteriological swabs

C Bacteriological swabs should only be taken where there is clinical evidence of infection.

3.3.4 Dermatitis/eczema

D Leg ulcer patients with dermatitis/eczema should be considered for patch-testing using a leg ulcer series.

3.5 Criteria for specialist referral

D Patients who have the following features should be referred to the appropriate specialist at an early stage of management:

suspicion of malignancy
peripheral arterial disease (ABPI <0.8)
diabetes mellitus
rheumatoid arthritis/vasculitis
atypical distribution of ulcers
suspected contact dermatitis or dermatitis resistant to topical steroids
non-healing ulcer.

4.2.1 Cleansing

Ulcerated legs should be washed normally in tap water and carefully dried.

4.2.2 Debridement

D Sharp debridement should only be carried out by appropriately trained practitioners.

C Local anaesthetic cream (EMLA®) should be used to reduce the pain of sharp debridement in patients with venous leg ulcer.

4.3 Dressings

A Simple non-adherent dressings are recommended in the management of venous leg ulcers.

4.3.1Topical antimicrobials and antiseptics

B Honey dressings are not recommended in the routine treatment of patients with venous leg ulcers.

A Silver dressings are not recommended in the routine treatment of patients with venous leg ulcers.

Routine long term use of topical antiseptics and antimicrobials is not recommended.

4.4 Surrounding skin

Latex-free brands of compression bandages should be used routinely.

4.5.4 Recommendations for compression therapy

A High compression multicomponent bandaging should be routinely used for the treatment of venous leg ulcers.

Patients should be offered the strongest compression that maintains patient concordance.

At initiation of compression, patients should be assessed for skin complications within 24-48 hours.

In patients with an ABPI <0.8, and in patients with diabetes, compression should only be used under specialist advice and with close monitoring.

When considering the type of compression to use, practitioners should take into account:

patient preference, lifestyle and likely concordance
required frequency of application
practitioner level of expertise
size and shape of leg.

Compression should only be applied by staff with appropriate training and in accordance with the manufacturer’s instructions.

4.6.1 Antibiotics

C In patients with chronic venous leg ulcers, systemic antibiotics should not be used unless there is evidence of clinical infection.

4.6.2 Pharmacological agents used to increase healing rates

A Use of pentoxifylline (400 mg three times daily for up to six months) to improve healing should be considered in patients with venous leg ulcers.

4.11.1 Exercise

Supervised calf muscle exercise should be considered in patients with venous leg ulcer.

5.1 Graduated compression for healed venous ulceration

A Below-knee graduated compression hosiery is recommended to prevent recurrence of venous leg ulcer in patients where leg ulcer healing has been achieved.

Patients should be offered the strongest compression which they can tolerate to prevent ulcer recurrence.

Patients should be informed that it is likely that compression will be required indefinitely.

The concepts, practice, and hazards of graduated compression should be fully understood by those prescribing and fitting compression stockings.

5.2 Venous surgery

B Patients with chronic venous leg ulcer and superficial venous reflux should be considered for superficial venous surgery to prevent recurrence.

Assessment of venous reflux should be undertaken using duplex ultrasound.

6.3 Specialist leg ulcer clinics

B Specialist leg ulcer clinics are recommended as the optimal service for community treatment of venous leg ulcer.

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