Venous Leg Ulcer Pain

Siobhan Ryan, MD, FRCPC (Derm); Cathy Eager, RN, CWOCN, CWS; and R. Gary Sibbald, MD, FRCPC (Med)(Derm)

Treat the Cause
Venous disease may progress to ulcer formation. Ulcers are often serpiginous and seen around the ankle or lower calf region (gaiter area). Lipodermatosclerosis often precedes the development of venous ulcers but is not always present. Venous leg ulcers are the most common cause of all leg ulcers and increase in frequency with advancing age of the patient.1 The typical venous leg ulcer occurs around the medial aspect of the ankle or lower leg and is often shallow with irregular borders presenting on a background of skin changes related to chronic venous stasis.
Historically, venous ulcers have been considered to be relatively pain free. However, it is now known that a significant number of patients with venous ulcers will experience pain that has an impact on their quality of life (see Table 1).2-8 This pain may be constant or intermittent with procedures or dressing change. Evaluation of the location, frequency, and other factors associated with the pain are essential in the assessment and management of patients with venous disease. The clinician should keep in mind that patients may experience pain in the absence of an ulcer and may continue to have prolonged pain once an ulcer has healed.
Venous disease is a spectrum of changes that slowly evolve over time with a variety of associated pain symptoms ranging from discomfort and aching to deep, chronic pain. Acute, disabling pain may develop with each stage and will impact the plan of care for the patient (see Figure 1).
The management of pain is dependant on the diagnosis of the pain source (see Table 2). Clinically, dependent edema and a dilated saphenous vein are the early signs of venous disease. Patients with pitting edema and prominent varicose veins often will describe a dull aching or heaviness in their legs that progresses toward the end of the day or after prolonged periods of standing. Support stockings, ambulation, and leg elevation while sitting will often relieve these symptoms. Attention also should focus on other factors contributing to venous stasis disease such as obesity, sedentary life style, and other comorbid illnesses.
Assessment of the status of venous disease to determine the extent of venous incompetence or venous obstruction can be performed at the bedside or in a vascular laboratory. Measurement of the ankle brachial index (ABI) by Doppler is important to determine co-existing arterial disease. Use of inappropriate compression bandaging in a patient with arterial insufficiency may lead to worsening of the ulcer and more serious complications. Ulcers related to peripheral vascular insufficiency have always been considered quite painful, but this feature alone is not adequate to differentiate between an ulcer of venous stasis etiology and vascular insufficiency.
Lipodermatosclerosis. Long standing pitting edema leads to pigmentary changes on the distal one-third to one-half of each leg. This pigmentary change is related to deposition of hemosiderin from extravasated red blood cells and stimulated melanin. This change presents as reddish brown to dark brown nonpalpable discoloration that may initially be somewhat speckled and chronically becomes confluent and circumferential. Over time, this pigmented area becomes sclerotic, due to the leakage of fibrin, with a deep dermal fibrosis that may extend from the ankle to mid-way up the leg. It is often described as resembling an inverted "champagne bottle," as the upper one half of the leg remains edematous and has a much greater circumference than the lower sclerotic portion. Edema, sclerosis, and pigmentation together make the diagnosis of lipodermatosclerosis.
These clinical changes on the lower legs represent long-standing venous stasis and will vary in degree from patient to patient. The visible changes present do not always correlate with the degree of pain the patient feels. In a review of 97 cases of lipodermatosclerosis, 43% of patients reported pain was the most common symptom.9
Lipodermatosclerosis may be further divided clinically into acute and chronic forms. The acute form shows more edema and more erythema with less sclerosis and less pigmentation than the chronic form. Acute lipodermatosclerosis is sometimes mistaken for cellulitis, especially if it is unilateral. However, venous stasis changes are rarely unilateral and are often bilateral, although the disease may have some asymmetry in terms of severity.
Management of lipodermatosclerosis includes compression bandaging or support stockings, topical medications including topical steroids and lubricants, and oral medication including nonsteroidal anti-inflammatory drugs or pentoxifylline. Patients with lipodermatosclerosis may require custom-fit support stockings because of their unusual leg shape. The amount of compression obtained is dependent on what is tolerable, affordable, and medically acceptable. Low compression (class 1) may be adequate to obtain control of dermal edema in lipodermatosclerosis,10 although high levels of compression, if achievable, are ideal.
Nonelastic support systems do not exert pressure at rest, making them less likely to cause pain. Short-stretch bandages, paste wraps such as an Unna's boot, and inelastic garments would be examples of nonelastic support systems (see Table 3).11
Support stockings may be adequate to control the symptoms of lipodermatosclerosis; however, nonsteroidal, anti-inflammatory medications may be needed. Ketoprofen (50 mg one to three times per day), diclofenac (75 mg twice a day), and naproxen (500 mg twice a day) all have been used as both analgesic and anti-inflammatory agents for control of lipodermatosclerosis. Adverse effects of these medications must be considered before use. Superficial or deep phlebitis also must be considered when patients describe a new acute pain or a change in the character of pre-existing pain. The pain associated with superficial phlebitis tends to be localized over a portion of the involved vein - usually the saphenous vein. Patients will sometimes describe the pain as bruise-like in nature. The pain is often aggravated by palpation or standing and the involved area may show increased heat and tenderness. Treatment options for superficial thrombophlebitis include compression, ambulation, and NSAID therapy. Doses are similar to those used for control of lipodermatosclerosis. The use of newer COX-2 inhibitors has not yet been established in the management of superficial phlebitis and may not be of benefit because they have little effect on platelet aggregation.
Deep vein thrombosis. Deep vein thrombosis (DVT) may be extremely painful, especially in the posterior calf region. Patients often do not tolerate pressure on the calf muscle and find that dorsiflexion of the foot is too painful to perform. The involved leg is often swollen and may be red, leading to confusion with cellulitis. Management of DVT includes use of anticoagulants including acetylsalicylic acid (ASA), unfractionated heparin, warfarin, and low-molecular-weight heparin, as well as bed rest. When patients with superficial thrombophlebitis are globally screened, the association of DVT is uncommon; hence, looking for DVT without the presence of other risk factors (ie, immobilization and oral contraceptives) is unnecessary.12
Dermatitis. Another factor that complicates venous disease and venous ulcers is the presence of dermatitis, especially periwound dermatitis.13,14 Products used on the distal legs of patients with venous stasis either in the presence or absence of ulcers must be relatively free of potential contact allergens and irritants.15 Adhesives, tulles (paraffin gauzes), topical lubricants and emollients, topical antibiotics, and other wound and periwound products all contain agents that may lead to a contact dermatitis.16-21 Patients will complain of burning and itching usually in the distribution of the product use. A change in the type of pain or discomfort that a patient experiences in association with eczematous changes on the skin would suggest a diagnosis of either irritant contact or allergic contact dermatitis.22
Atrophie blanche. Atrophie blanche is one of many of the "end stages" of venous disease. Idiopathic atrophie blanche is a definitive clinical finding that consists of distinct white, sometimes star-shaped depressed scar-like areas.23 It develops spontaneously and more often than not is associated with severe, sharp pain. Managing the pain of atrophie blanche often is a challenge and may require analgesic medication. This feature is seen in association with both venous stasis and vascular insufficiency. Areas of atrophie blanche are sometimes confused with the scars that develop at the sites of healed venous stasis ulcers, but the patient often can provide the history to help distinguish these two entities.

Patient-Centered Concerns
Numerous articles on the pathophysiology of venous leg ulcers indicate that pain is a major concern for patients and practitioners.11,24 In an effort to address this issue, one facility established a program in an outpatient clinic to reduce pain during dressing changes.25
As part of this program, a minimally directed interview process was conducted with the outpatient population to gather pain data. In a previous study of venous ulcer pain, Krasner26 investigated patient pain response through an interview process focused on quality-of-life issues. For the current study, the focus was on the relationship between treatment processes and pain relief and the patient's interpretation of symptoms and pain. The selection process included all patients with venous insufficiency ulcers receiving wound care in the outpatient setting. Interviews took place over a 3-month period. Informed consent involved a full explanation of the questions and a statement that the findings will be used for staff and medical practitioner teaching. The outpatient clinic is part of faculty practice in a teaching hospital. Admission forms included a consent form covering these practices. The responses were recorded in the patients' own words on a separate form without any patient identification. A copy of responses was placed in the patient chart. All patient participants had the right to refuse participation. (Interviews are continuing as new patients are admitted for venous ulcer treatment). The questions are deliberately open-ended, allowing the patient to relate his/her experiences in his/her own words. The initial inquiry occurs at admission to the outpatient program, with follow-up questions at the second visit. The participant's ages ranged from 40 to 92 years of age (see Table 4). Thus far, 26 patients have completed the interview process - 12 men and 14 women. The patients have had their ulcers from 2 months to several decades; 45% of the ulcers have been present for less than 12 months and the other 55% have been present for more than 1 year. The largest group in the study (50%) is between the ages of 60 to 72 years.
The group most concerned with pain relief (77%) were the patients aged between 60 to 70 years.
Of participants between 40 to 50 years of age, 83% were more concerned with quality-of-life issues than pain. The age group ages >70 years cited worry/anxiety (40%) and pruritis (60%) as their greatest concerns (see Table 5). These findings may change as more interviews are completed.
Providers frequently assume they accurately interpret patient symptoms.27 The current study has discovered that these patients have many issues in addition to their venous ulcers. Some participants felt the ulcer would never heal and that suffering would be a permanent part of their lives. Participants shared the most significant symptom related to their disease process (see Table 6) and their survey responses were summarized (see Table 7).
The results of a recent survey28 conducted of 210 nurses performing wound care demonstrate a great need for education related to pain and wound care. When these nurses were asked what they considered the most important wound care outcome, pain reduction ranked third.
* Time to healing 39%
* Limb preservation 28%
* Reduction in pain 14%
* Identifying effective products 14%
* Other 4%
From this study, current researchers concluded that long-term care nurses and nurses who spent 50% of their time in wound care named pain as the third biggest issue after time to healing and limb preservation. On the other hand, patients identified addressing pain and quality-of-life issues as most important.

Local Wound Care
Moisture balance, debridement, and bacterial balance/controlled inflammation29 are three factors that must be considered in the local management of venous ulcers. The presence of pain will impact significantly on the control of each of these three factors.
Moisture balance. Limiting exudate and achieving moisture balance is important in venous ulcers. Often, the wound care product of choice is, initially, a foam, soft silicone, or alginate. Exudative wounds often require frequent dressing changes, which patients say contributes to the acute recurrent pain. Choosing a product that is absorbent and non-traumatic will reduce the frequency of dressing changes and the associated pain, respectively.
Debridement. Debriding venous leg ulcers can be achieved through a number of methods. Sharp surgical debridement often is not necessary and when performed may be quite painful. Topical anesthetics may be used to alleviate this type of procedural pain.30 Agents such as EMLA (not approved for open wounds in the US but available in Canada and many other countries) or topical xylocaine (1% to 4%) ointments or gels have been used clinically in appropriate settings. Autolytic debriding agents are useful, particularly hydrogels or hydrocolloids. In some cases, the use of such agents may help reduce the associated pain. Mechanical debridement using wet-to-dry dressings is generally too painful to be tolerated, especially when more beneficial alternatives exist. Enzymatic debriding agents are used for thick, adherent eschar as an alternative to hydrocolloids or hydrogels.
Bacterial balance. Bacterial balance is essential for wound healing. Topical antimicrobial agents play a role in the wound where the bacterial load appears to be impairing wound healing. Agents such as cadexomer iodine or ionized silver are generally well tolerated, although some patients experience burning pain, especially immediately after the application of these products. Patients will note that the localized wound pain tends to occur or worsen soon after a dressing change. In this situation, patients should rate the quality and duration of that pain so appropriate pain management can be instituted before future dressing changes.
If bacterial balance is not achieved or infection occurs, an associated change in the quality of pain or increase in pain intensity often occurs. Patients who complain of a new or worsening of pain should be assessed for infection. Signs of local wound infection include an increase in exudate, size, or odor. Periwound skin may show a temperature elevation. If the infection extends beyond the wound, cellulitis may be diagnosed and systemic symptoms may be present. Cellulitis may be diffusely painful, and the red, hot limb may be extremely sensitive to touch. Systemic antibiotics will be necessary; the choice of antibiotic depends on the organism involved, the antimicrobial sensitivities, previous antibiotic use, the duration of the wound, and host resistance.

Patients with venous disease and venous ulcers must manage their edema on an ongoing basis. Once the ulcer heals, they should be advised to wear support stockings for life. Pain control is an integral part of the management of a patient with venous stasis disease and venous stasis ulcers. Edema control is essential for pain control; it is an ongoing problem for both caregivers and patients.
The approach to venous ulcer pain must include an assessment of the cause of pain and the pain characteristics (constant or intermittent). Treatment can be local (eg, dressings and topical anesthetic agents), regional (support rather than compression bandaging) or systemic (NSAIDs or other intermittent or long acting pain medications). - OWM


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