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First aid dressings account for only a fraction of NHS spend in the wound care category. Of far greater financial significance is the management of chronic wounds and, in particular, leg ulcers.
These sores of the lower limb – most commonly located on the inside of the leg, just above the ankle – can take many weeks to heal and be expensive to treat. The typical cost of managing a leg ulcer is thought to be in excess of £6,000 per patient.
Venous leg ulcers account for around 80 per cent of all leg ulcers. What initially seems to be a relatively minor knock fails to heal in the expected one to two week time frame, usually because of an underlying problem with the veins in the leg. This may be due to mobility issues – osteoarthritis or obesity, for example, or perhaps a recent fracture or surgery – or varicose veins.
Whatever the root cause, the effect of constant high blood pressure inside the veins slowly damages the capillaries near the skin surface, making it much more fragile than before.
There are often warning signs that an injury is not healing as normally expected. Brown spots and patches may appear on the skin, and the altered blood flow can turn the skin various shades between red and blue.
Other red flag symptoms include swelling of the leg, finding it painful to stand for long periods, and the skin becoming itchy and scaly with firm, tender areas underneath. Once it has developed, an ulcer has a distinctive appearance. The bed of the ulcer may show bumpy, moist and red healing tissue, or may be covered in a yellowish-grey layer. Ulcers often leak fluid, the amount of which can vary.
Leg ulcers are susceptible to bacterial infection, which is usually indicated by an increase in pain, redness and swelling around the sore, a significant quantity of green or unpleasant pus oozing from the site, and a fever.
The management of uncomplicated venous leg ulcers usually involves several steps:
• The wound must be cleaned to remove slough and any necrotic, fibrous or excess granulation tissue – this is achieved by irrigation and gentle washing. Occasionally debridement (surgical excision of dead tissue or cellular debris) may be necessary
• The wound is then dressed using a low-adherent dressing, but employing a hydrocolloid, alginate or hydrogel product if pain, heavy exudate or sloughing respectively is an issue. Compression therapy is then applied below the knee – two layers if the patient is mobile; three or four if they are not. This reduces venous reflux and ankle oedema, and increases venous blood flow, which in turn improves circulation and healing
• The patient should be followed up at least weekly for the first couple of weeks in order that dressings can be changed and the healing process evaluated. This also provides a useful opportunity to check on the patient’s compliance with their prescribed compression therapy and their general well-being. Once the ulcer is healing, appointments can be stretched out to fortnightly, then monthly, and finally every three months.
It is important to support patients with venous leg ulcers and their carers, particularly when it comes to providing encouragement and advice on some of the problems commonly experienced.
Oedema can be reduced by regular exercise and keeping the affected leg raised while inactive. Less mobile people can also exercise their leg muscles by moving their foot up and down at the ankle.
Dry skin and eczema can occur around the ulcer, so advice on how to keep this area moisturised effectively through the regular use of emollients is useful.
Community pharmacy teams can also provide advice on compression product care. Patients should follow the instructions carefully, as washing at the wrong temperature can damage the elastic. Patients also need to make sure compression products are replaced every three to six months because, over time, they lose their elasticity.
People with scars can be upset about the appearance of their skin and often need support from a healthcare professional.
The healing process can be very individual and depends on the actual type and size of scar, the age of the patient and their general health. Most scars go through four distinct stages of healing, with immediate healing taking up to two to three weeks, but the final formation of a scar can take up to two years. If a person is very distressed, referral to a psychologist, dermatologist or plastic surgeon may be needed.
Pharmacists are one of the healthcare professionals most likely to have regular contact with patients concerned about scars. As they often supply the products used to support the management of scars, they are ideally placed to give self-care guidance.
The longer a wound takes to heal, the worse the scar is in appearance. Keeping the wound clean, avoiding stretching and stopping infection are key in preventing healing delays.
Once a wound has healed, there will almost always be a scar that may be red, raised, stretched or continually active. Massaging a scar will soften it and reduce redness. Sometimes, however, despite these steps, a scar remains active and/or raised.
The best opportunity to treat a scar is when it is new but it is important to wait until the wound has fully healed and allow four weeks after any stitches have been removed before commencing scar massage.
Keeping it hydrated (for example, with specialised oil), not going in the sun and not stretching it, will reduce the appearance of a scar. Once scars become old, they can be more difficult to treat unless abnormal, such as keloid scars. Surgical remoulding may be necessary to encourage new collagen formation.
Venous leg ulcers account for around 80 per cent of all leg ulcers