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Farid Blog: Venous Stasis Dermatitis/Ulcerations Management

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Farid Blog: Venous Stasis Dermatitis/Ulcerations Management


Venous stasis dermatitis and associated ulcerations are common in the elderly, most likely due to decreased activity and hours of sitting. This is a problem also is common among persons limited to wheelchair mobilization (with legs in the dependent position for hours at a time) and among people with an injury and/or a neurological deficit in 1 or both lower extremities, even with ambulation. The lower extremity venous return relies on the “kneading” action of the musculature to assist with the pumping of the venous blood supply to return it to the central circulation (see Orr et al. in the August 2017 issue of OWM). 

Venous stasis disease also is seen in people with congestive heart failure and/or renal impairment that results in lower extremity edema. The patient (and where necessary, the patient’s nurses and family and friend caregivers) needs to keep the physician informed regarding the presence of edema and any signs of inflammation. Often a diuretic and/or adjustment of the patient’s medications will relieve the symptoms. If these measures do not resolve the problem, preventive support stockings and leg elevation can be utilized to prevent the more serious problems of cellulitis and ulcerations. 
Presentation. Venous stasis symptomatology includes edematous swelling of the lower extremities that is usually limited to below the knee. If limited to 1 leg, measuring and comparing the circumference of both legs is helpful in monitoring the progress of the affected leg. Whether the edema is present in 1 or both legs, the extra weight of the lower leg(s) often causes falls and injury and/or ulceration and infection. This should be explained and emphasized to the patient in order to impress the need for the patient to partner with professionals in the healing and prevention program.
Another important symptom in the visual assessment of venous stasis disease is a brownish discoloration of the lower legs from ankles to mid-calf and sometimes to below the knee. This condition is caused by the congestion of the vasculature capillary bed just under the skin. The capillaries and red blood cells rupture, and the iron/hemoglobin component (hemociderin) of the blood is deposited in the dermis (hemociderin staining). This congestion is often accompanied by cellulitis of the lower leg. Microfissures of the skin occur due to excessive stretching of the skin and allow bacteria/fungi to enter, causing further inflammation and congestion and rendering the body’s normal defenses against local infection ineffective. Inability to clear the area of inflammatory cytokines and histamines released by the cells creates a vicious cycle of more inflammation; the edema reaches critical mass causing the skin to ulcerate. Superficial ulcerations, generalized cellulitis of the lower leg, weeping edema, and often full-thickness ulcers occur. The weeping and ulcerations are usually worst along the medial aspect of the lower leg above the medial malleolus.
Treatment. The treatment of acute venous stasis cellulitis and dermatitis/ulcers involves systemic antibiotics (most commonly cephalexin, amoxicillin, doxycycline, ciprofloxacin), elevation of the leg, and topical cleansing with Dakin’s solution (.25 concentration) with each dressing change, and application of gentian violet 1% with a calcium alginate cover dressing to the areas of worst weeping and ulceration (gentian violet is very penetrating and is very effective in targeting Streptococcus, Staphylococcus, fungus, and other troublesome skin organisms; it also has a drying effect). Once the weeping decreases with treatment, topical calamine/cortisone is helpful in reducing the skin inflammation and pruritus, increasing general comfort on the nonulcerated areas. 
Empowering patients is very important in the treatment and prevention of recurrence of venous stasis disease. Education is essential. Clinicians need to be aware of the patient’s and family’s limitations in managing the symptoms. Also, the clinicians directing care need to incorporate mobility into the plan of care. Elderly people can physically and mentally deteriorate rapidly when mobility is restricted. As soon as the pain subsides (usually 1 to 3 days after the start of antibiotics), elastic bandage wraps can be applied, and the patient can be encouraged to walk, use stairs (with assistance if necessary), and sit at the table for meals. When the patient is up and around, he/she often will complain of gradually increasing pain as fluid naturally settles into the legs and blame it on the support stockings being too tight, demanding that someone remove the stockings). This is an opportune time for education and empowerment. After explaining the tendency for the fluid pressure to increase the longer the patient is upright, you can affirm that the problem is not the stockings  — instead, the pain is the signal for the patient to sit for a while and elevate his lower legs. 
Support/compression is a tool patients with venous “insufficiency” (the “steady state” of controlled venous stasis) need to prevent future ulcerations and infection. However, the clinician should realize compression stockings are of no use to the patient if the patient will not wear them. Clinicians often privately label venous insufficiency/stasis patients the most nonadherent to protocol because they do not use the prescription stockings. However, I have found that to treat and prevent venous stasis conditions, prescription stockings are not needed for most cases; they are expensive and patients need to see a professional to get fitted for them even if they are covered by insurance. In addition, patients (especially the elderly) can be frustrated by their inability to don the stockings. 
To address these concerns, I use a nonprescription Medichoice tubular support stocking or Convatec’s “Tubigrip.” I buy 4-inch and 4.5-inch widths on 1-yard rolls so I can cut pairs of stockings off for any length legs. The wider width is good for applying over bandages. Over the years, these easy-to-apply tubular support stockings provide a level of compression sufficient to prevent congestion of the skin, dermatitis, and ulcerations. I also like to layer support; for example, I use elastic conforming gauze rolls to secure dressings, applying them in the same configuration as an elastic bandage wrap from the instep of the foot to below the knee (often needing more than one). Then I apply the tubular support stocking over it. When treating wound care patients in the nursing home, I realized that even the seemingly nonexistent support of these conforming bandages was much greater than I thought. Two notes of caution: 1) If they are not applied correctly (i.e., evenly over the desired area), they can constrict as they do when they are wrapped over and over the same spot; and 2) people who have had and who are prone to deep vein thrombosis should be advised to procure and wear the prescription compression stockings; devices are available to help don and remove compression stockings.
In general, when not being treated for venous stasis dermatitis/ulcerations, patients should sit with their legs elevated, and when they are up an around and/or sitting at the table, they should be advised to wear their tubular support stockings or other support stockings. Many of my patients also like to wear their support stockings in bed, although this is not necessary. 
As part of my clinical specialist role, educating other clinicians, nurses, ancillary personnel, and patients is among my most important goals. I learned early on that if you do not make a task easier (for yourself and especially for the patient) and have the required equipment available, you will have a high degree of protocol nonadherence. Try a few of these pointers and let me know if they work and share any tips you may have to put a wrap on venous disease.