LEG ULCERS, COMPLICATED

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A chronic relapsing disorder of the lower limbs, which usually occurs in middle-aged women. It has many causes and is often associated with lipodermatosclerosis (bound-down, fibrosed skin) and eczema. It is mainly associated with vascular, predominantly venous insufficiency and immobility. It is also associated with neuropathy and, occasionally, with infections, neoplasia, trauma or other rare conditions.

GENERAL MEASURES

The aim of management should be to:

»      Treat underlying conditions, e.g. Heart failure, diabetes mellitus and stasis.

»      Limit the extent of damage.

»    Encourage rapid healing to minimise scarring and fibrosis.

»      Prevent recurrences.

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Avoid all topical irritants and allergens, e.g. lanolin, neomycin, bacitracin, parabens, fusidic acid, clioquinol, antihistamine creams, etc.

If the ulcer is oedema- or stasis-related, rest the leg in an elevated position.  In venous insufficiency, compression (bandages or stockings) is essential to achieve and maintain healing, provided the arterial supply is normal.

In patients with arterial insufficiency, avoid pressure on bony prominences and the toes. Stress meticulous foot care and avoidance of minor trauma.

Walking and exercises are recommended.

Encourage patients with neuropathy not to walk barefoot, to check their shoes for foreign objects, examine their feet daily for trauma and to test bath water before bathing to prevent getting burnt. Avoid excessive local heat.

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Indications for surgical procedures include:

»      slough removal,

»             surgery for varicose veins,

»             arterial insufficiency, and

»               skin grafting.

MEDICINE TREATMENT

Antibiotic therapy

Systemic antibiotics are seldom required for ulcers, and should be considered only if there is surrounding cellulitis. These infections are typically polymicrobial and broad-spectrum antibiotics are recommended.

  • Amoxicillin/clavulanic acid, oral, 875/125 mg 12 hourly for 7 days.

Local wound care Topical cleansing

Use bland, non-toxic products to clean the ulcer and surrounding skin.

For clean uninfected wounds:

  • Sodium chloride 0.9% or sterile water.

For exudative, infected wounds:

  • Povidone-iodine 5% cream, topical apply daily.
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