{"id":110,"date":"2025-10-01T20:33:58","date_gmt":"2025-10-01T20:33:58","guid":{"rendered":"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/?page_id=110"},"modified":"2025-10-16T03:24:44","modified_gmt":"2025-10-16T03:24:44","slug":"chronic-venous-insufficiency-and-leg-ulcers","status":"publish","type":"page","link":"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/index.php\/chronic-venous-insufficiency-and-leg-ulcers\/","title":{"rendered":"Chronic Venous Insufficiency and Leg Ulcers"},"content":{"rendered":"<div class=\"wpb-content-wrapper\">[vc_row full_width=&#8221;stretch_row&#8221; content_placement=&#8221;middle&#8221; equal_height=&#8221;yes&#8221; rtl_reverse=&#8221;yes&#8221; remove_bottom_col_margin=&#8221;true&#8221; columns_right=&#8221;yes&#8221; wpex_bg_color=&#8221;#03a3de&#8221; min_height=&#8221;350px&#8221;][vc_column width=&#8221;1\/2&#8243;]<style>.vcex-image.vcex_69d07517e4564 .vcex-image-img{object-position:right top;}<\/style><figure class=\"vcex-image vcex-module vcex-fill-column vcex_69d07517e4564\"><div class=\"vcex-image-inner wpex-relative wpex-w-100 vc_custom_1760585083023\"><img width=\"1210\" height=\"657\" src=\"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/wp-content\/uploads\/2025\/10\/Chronic-Venous-_Insufficiency-Leg-Ulcers_-copy.webp\" class=\"vcex-image-img wpex-align-middle wpex-w-100\" alt=\"\" loading=\"lazy\" decoding=\"async\" srcset=\"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/wp-content\/uploads\/2025\/10\/Chronic-Venous-_Insufficiency-Leg-Ulcers_-copy.webp 1210w, https:\/\/cmcdeploytwo.co.nz\/vsoanz\/wp-content\/uploads\/2025\/10\/Chronic-Venous-_Insufficiency-Leg-Ulcers_-copy-300x163.webp 300w, https:\/\/cmcdeploytwo.co.nz\/vsoanz\/wp-content\/uploads\/2025\/10\/Chronic-Venous-_Insufficiency-Leg-Ulcers_-copy-1024x556.webp 1024w, https:\/\/cmcdeploytwo.co.nz\/vsoanz\/wp-content\/uploads\/2025\/10\/Chronic-Venous-_Insufficiency-Leg-Ulcers_-copy-768x417.webp 768w\" sizes=\"auto, (max-width: 1210px) 100vw, 1210px\" \/><\/div><\/figure>[\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text css=&#8221;.vc_custom_1759350475966{padding-top: 20px !important;padding-bottom: 20px !important;}&#8221; color=&#8221;#fefefe&#8221;]\n<h1><strong>Chronic Venous Insufficiency<\/strong><br \/>\nand Leg Ulcers<\/h1>\n[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1759015527111{margin-top: 60px !important;}&#8221;][vc_column][vc_tta_tour controls_size=&#8221;md&#8221; active_section=&#8221;1&#8243;][vc_tta_section title=&#8221;Background&#8221; tab_id=&#8221;1759012899351-dcaaabe1-cd5c3721-8edc&#8221;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">Background<\/h2>\n<p>Chronic venous insufficiency and leg ulcers affect approximately 1-2 people per 1000 of the general population, with approximately 10-20 people per 1000 ever affected. Ulcer healing rates can be poor with up to 50% of venous ulcers open and unhealed for 9 months. Ulcer recurrence rates are worrying with up to one third of treated patients on their fourth or more episode. In the UK leg ulcer treatment accounts for 1.3% of the total healthcare budget and up to 90% are treated in the community.\u00a0 In the United States venous ulcers have been estimated to cause the loss of 2 million working days and to incur treatment costs of approximately $3 billion per year (<a href=\"http:\/\/www.medicine.wisc.edu\/~williams\/chronic_venous_disease.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Bergan JJ et al, 2006<\/a>).[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;What is chronic venous insufficiency?&#8221; tab_id=&#8221;1759012899354-da1d8fff-c0983721-8edc&#8221;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">What is chronic venous insufficiency?<\/h2>\n<p>Chronic venous insufficiency is a term used to describe the changes that can take place in the tissues of the leg, due to longstanding high pressure in the veins.\u00a0 This high pressure in the veins usually occurs because blood flow in the veins is abnormal, secondary to valvular incompetence, causing reflux (reverse flow) in the veins.\u00a0 High venous pressure may also occur if the veins in the legs become blocked, but this is much less common.\u00a0 In many patients varicose veins will also be present in conjunction with chronic venous insufficiency, but this is not always the case.\u00a0 There are many patients with typical changes of chronic venous insufficiency, but no obvious problem with their superficial veins.\u00a0 These patients may have abnormalities in the deeper veins which will only be apparent on special scans.<\/p>\n<p>The prolonged high pressures in varicose veins appear to lead to low level chronic inflammation in the surrounding tissues and to ultimately produce the clinical changes described below.<\/p>\n<p>There are some factors which appear to predispose patients to chronic venous insufficiency.\u00a0Correctable factors include being overweight, physically inactive and smoking.\u00a0 Age and a family history of venous disease cannot be altered but do increase your risk.\u00a0 The San Diego study also found that hours standing was a risk factor in women (<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2023874\/pdf\/nihms28091.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">San Diego study<\/a>).[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;What are the changes that occur in chronic venous insufficiency?&#8221; tab_id=&#8221;1759014772115-45b909ba-03383721-8edc&#8221;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">What are the changes that occur in chronic venous insufficiency?<\/h2>\n<p>Chronic venous insufficiency is a general term which encompasses a number of different changes that can occur in the gaiter area of the leg (the lower half of the leg above the ankle and around the ankle).\u00a0 The classical changes are described below:<\/p>\n<p><strong>Pigmentation<br \/>\n<\/strong>A brown discolouration of the skin can develop in the gaiter area (just above the ankle) and is a typical sign of venous disease.\u00a0 The brown discolouration occurs when blood cells leak out of the blood vessels.\u00a0 Haemoglobin from the red blood cells is broken down into a compound called haemosiderin, which is then permanently deposited in the tissues.\u00a0 This can commonly occur after a significant injury to the leg and will be made worse by an underlying problem in the veins.<\/p>\n<p><strong>Ulceration<br \/>\n<\/strong>In some patients damage to the tissues can become so bad that an area of skin can be lost.\u00a0 When an area of skin is lost the raw area left behind is called an ulcer.\u00a0 Ulcers can vary from being very small to very large.\u00a0 Some patients become very worried when they hear they have an ulcer.\u00a0 Ulcers can certainly be very troublesome, but the term ulcer only means that an area of skin has been lost.\u00a0 It does not have any more serious underlying connotations.<\/p>\n<p><strong>Lipodermatosclerosis (LDS or liposclerosis)<br \/>\n<\/strong>This refers to a thickening in the tissues underneath the skin.\u00a0 It can only be detected by feeling the leg.\u00a0 It is a very obvious change in the tissues.\u00a0 They become hard and woody and lose all their normal suppleness.\u00a0 It is particularly obvious in some patients with varicose veins.\u00a0 This is because it can be easy to feel the difference between the relatively soft and compressible vein and the surrounding hard, incompressible tissues.<\/p>\n<p><strong>Varicose eczema<br \/>\n<\/strong>When this develops, the skin becomes red, wet and scaly.\u00a0 It can vary from a relatively small localised area with very mild changes, to a situation where the whole shank of the leg is involved and the skin can appear very angry and inflamed.<\/p>\n<figure id=\"attachment_112\" aria-describedby=\"caption-attachment-112\" style=\"width: 141px\" class=\"wp-caption alignnone\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-112\" src=\"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/wp-content\/uploads\/2025\/10\/Venous-Ulcers.jpg\" alt=\"Venous Ulcers\" width=\"141\" height=\"198\" \/><figcaption id=\"caption-attachment-112\" class=\"wp-caption-text\">Venous Ulcers<\/figcaption><\/figure>\n<p>The picture shows ulceration with eczema and inverted champagne bottle appearance.<\/p>\n<p><strong>Abnormal appearance to the shape of the leg (inverted champagne bottle)<\/strong><br \/>\nAn inverted champagne bottle aptly describes the appearances of some legs with chronic venous insufficiency. The leg is very narrow at the ankle and just above, but then becomes much fatter in the upper part of the calf below the knee. This is commonly associated with pigmentation around the ankle and sometimes with varicose veins.<\/p>\n<p><strong>Swelling<\/strong><br \/>\nSwelling around the ankle, foot and lower leg especially of a mild degree can occur in many patients with venous problems. If it becomes more severe and is only present in one leg, then it can be a sign that investigation and treatment of the venous system is required.<\/p>\n<p>The impairment in the quality of life of patients with leg ulcers is comparable with patients suffering from heart failure and chronic lung disease (Carradice 2011).[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;What is an ulcer?&#8221; tab_id=&#8221;1759014806183-f54d1997-de0b3721-8edc&#8221;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">What is an ulcer?<\/h2>\n<p>Mention of an ulcer often concerns patients.\u00a0 An ulcer is simply an area that has lost the covering layer of skin so that the tissues beneath the skin are exposed.\u00a0 This is all that is meant by an ulcer.\u00a0 It does not say anything about the cause of the ulcer or how it will respond to treatment.<\/p>\n<p>There is an important distinction between an ulcer and a graze on the leg.\u00a0 In the case of a graze only the superficial layers of the skin are lost even though this can be deep enough to cause bleeding. In an ulcer the whole thickness of the skin is lost and there are no skin cells in the defect.\u00a0 This difference has important implications for healing.\u00a0 In the case of a graze healing can take place over the whole graze, as there are still skin cells over the whole area. Healing is quick (5-10 days) because of these cells.\u00a0 In an ulcer the only way skin cells can bridge the ulcer and heal over is for the cells to grow in from the edges.\u00a0 This is a much slower process even in perfect conditions.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;What causes leg ulcers?&#8221; tab_id=&#8221;1759014827533-6ef99622-00a93721-8edc&#8221;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">What causes leg ulcers?<\/h2>\n<p>Leg ulcers are caused by two main problems in developed countries.\u00a0 The two commonest causes of ulceration are diseases of the veins and diseases of the arteries.\u00a0 As many as 75% of patients have a significant venous component to their leg ulcers. Arterial ulceration and mixed arterio-venous ulcers (ulcers due to a combination of venous and arterial disease) constitute the second major group of leg ulceration patients (14%). Diabetes mellitus can also cause ulceration, but predominantly in the foot. Venous and arterial problems can also occur in patients with diabetes.<\/p>\n<figure id=\"Causes of leg ulcers\" class=\"wp-block-table\">\n<table>\n<tbody>\n<tr>\n<th scope=\"col\">Causes of leg ulcers<\/th>\n<\/tr>\n<tr>\n<td>Post traumatic\/pressure sore<\/td>\n<\/tr>\n<tr>\n<td>Vascular<br \/>\nVenous (80-85% of all leg ulcers)<br \/>\nArterial including atherosclerotic, thrombo-angiitis obliterans, hypertensive<br \/>\nMixed Arterio-venous<\/td>\n<\/tr>\n<tr>\n<td>Lymphatic<\/td>\n<\/tr>\n<tr>\n<td>Vasculitic<br \/>\nRheumatoid arthritis<br \/>\nSystemic lupus erythematosus<br \/>\nAllergy<br \/>\nPyoderma gangrenosum<br \/>\nWegener\u2019s granulomatosis<br \/>\nScleroderma<\/td>\n<\/tr>\n<tr>\n<td>Metabolic<br \/>\nDiabetes mellitus<br \/>\nNecrobiosis lipoidica diabeticorum<br \/>\nGout<\/td>\n<\/tr>\n<tr>\n<td>Haematological<br \/>\nPolycythaemia rubra vera<br \/>\nLeukaemia<br \/>\nSickle cell anaemia<br \/>\nThalassaemia<br \/>\nSpherocytosis<\/td>\n<\/tr>\n<tr>\n<td>Malignant<br \/>\nBasal Cell Carcinoma<br \/>\nSquamous cell carcinoma and pre-invasive lesions(Bowen\u2019s disease)<br \/>\nMelanoma<br \/>\nLymphoma<\/td>\n<\/tr>\n<tr>\n<td>Infectious<br \/>\nBacterial<br \/>\nTubercular\/mycobacterial<br \/>\nFungal<br \/>\nSyphilitic<br \/>\nTropical ulcer<\/td>\n<\/tr>\n<tr>\n<td>Miscellaneous<br \/>\nDrug induced eg hydroxyurea<br \/>\nSelf inflicted<br \/>\nPost-irradiation<br \/>\nBurns, Frostbite<br \/>\nInsect bites<br \/>\nSarcoidosis<\/td>\n<\/tr>\n<tr>\n<td>This is not an exhaustive list of causes of leg ulcers<\/td>\n<\/tr>\n<\/tbody>\n<\/table><figcaption>Common causes of leg ulcers<\/figcaption><\/figure>\n<p>Sometimes ulcers can be due to skin cancers, although the majority of ulcers on the legs are not skin cancers.\u00a0 Rarely, a longstanding leg ulcer may develop into a skin cancer, usually a squamous cell carcinoma, commonly known as a Marjolin\u2019s ulcer. The table on the right gives a list of possible causes for leg ulcers. It is not an exhaustive list and many are very uncommon and not all universally recognised as true causes eg hypertensive ulceration.\u00a0 If you are aware of other causes of ulceration please e-mail me at feedback@vascular.co.nz and I will be happy to add them to the list. If you have images of rare types of ulcers I can also post them.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;What sort of assessment do I need?&#8221; tab_id=&#8221;1759014855534-cd1bf395-e3553721-8edc&#8221;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">What sort of assessment do I need?<\/h2>\n<p>An accurate\u00a0<a href=\"https:\/\/vascular-society.nz\/assessment-of-vascular-disease\/\" target=\"_blank\" rel=\"noreferrer noopener\" data-type=\"page\" data-id=\"121\">history and physical examination<\/a>\u00a0with special reference to venous and arterial disease, diabetes and rheumatoid arthritis is performed in all patients.<\/p>\n<p>A formal assessment of the arterial circulation using the hand held Doppler and measurement of the ankle-brachial index is essential before instituting treatment.<\/p>\n<p><a href=\"https:\/\/vascular-society.nz\/assessment-of-vascular-disease\/\" target=\"_blank\" rel=\"noreferrer noopener\" data-type=\"page\" data-id=\"121\">Duplex scan<\/a>\u00a0of the venous system will clearly identify patterns of venous reflux which can be surgically corrected in appropriate patients.<\/p>\n<p><strong>History<br \/>\n<\/strong>Information about how the ulcer developed and progressed is important.\u00a0 Many patients find their ulcer starts after a very minor injury which normally would be expected to heal.\u00a0 Because of underlying disease in the arteries or veins this doesn\u2019t happen and the ulcer deteriorates.\u00a0 Ulcers are less likely to be successfully treated if they have been present for a long time or if they are particularly large.<\/p>\n<p><a href=\"https:\/\/vascular-society.nz\/varicose-veins\/\" target=\"_blank\" rel=\"noreferrer noopener\" data-type=\"page\" data-id=\"90\">Varicose veins\u00a0<\/a>and previous\u00a0<a href=\"https:\/\/vascular-society.nz\/deep-venous-thrombosis\/\" target=\"_blank\" rel=\"noreferrer noopener\" data-type=\"page\" data-id=\"98\">deep venous thrombosis<\/a>\u00a0are possible contributing factors to the development of an ulcer.\u00a0 Previous surgery to the veins may be important in planning treatment.\u00a0 Your doctor will also ask about possible\u00a0<a href=\"https:\/\/vascular-society.nz\/atherosclerosis\/\" target=\"_blank\" rel=\"noreferrer noopener\" data-type=\"page\" data-id=\"119\">arterial problems<\/a>\u00a0in the legs.\u00a0 If you have suffered from\u00a0<a href=\"https:\/\/vascular-society.nz\/intermittent-claudication-pvd\/\" target=\"_blank\" rel=\"noreferrer noopener\" data-type=\"page\" data-id=\"113\">intermittent claudication<\/a>, previous ulcers or if you have had previous arterial bypass surgery to the legs, this will all be important.\u00a0 Your doctor will also ask about your general health and your mobility.<\/p>\n<p><strong>Examination<br \/>\n<\/strong>The examination will focus on the ulcer itself and on the arterial and venous systems in the leg.\u00a0 The site and size of the ulcer, the edge of the ulcer and the base of the ulcer are particularly important in deciding what sort of ulcer is present.\u00a0The appearance of the edge of the ulcer can raise suspicions of a possible skin cancer, but it also can indicate whether the ulcer is beginning to heal or if it is deteriorating.\u00a0 Very specific changes, such as a violaceous border, can indicate the presence of rare conditions such as pyoderma gangrenosum. The base of the ulcer can indicate if the ulcer will heal.\u00a0 Exposed bone or tendon, the presence of dead tissue or alternatively healthy granulation tissue are all important.\u00a0 Discharge, especially if smelly, can indicate the presence of infection. Discharge may be secondary to swelling in the leg.\u00a0 Constant discharge of fluid across the ulcer bed will impede healing.<\/p>\n<p>Obvious varicose veins will be recorded. The pulses will be felt throughout the leg and the arterial circulation further assessed through colour and warmth of the limb.<\/p>\n<p><strong>Investigations<\/strong><br \/>\nIn all patients the blood pressure should be measured at the ankle using the hand held Doppler.\u00a0 This instrument is a very sensitive tool for assessing blood flow in the leg, which is then compared against the blood flow in the arm.\u00a0 This enables the ankle:brachial index (ABI) to be calculated.\u00a0 Usually the flow of blood in the arms and legs is the same and the index is close to 1.0.\u00a0 If there is impairment of the circulation in the lower limbs then the index will be reduced to less than 1.0. The quality of the doppler signal is also important. A biphasic or triphasic signal will indicate good arterial flow even if the ABI is difficult to measure or pulses cannot be felt. It does need experience to be able to evaluate the doppler accurately.<\/p>\n<p>Hand Held Doppler can also be used in the clinic to assess the veins, but the assessment is not as accurate as the that in the arteries.\u00a0 All patients require a more detailed assessment of the veins using colour flow ultrasound.\u00a0 This test supplies detailed information about the anatomy of the system of veins and the direction of blood flow in the veins.<\/p>\n<p>If there is anything unusual about the appearance of the ulcer or if the ulcer persistently fails to heal a small piece of tissue should be removed (biopsy).\u00a0 This will check whether there is any underlying skin cancer and may also help with other diagnoses in certain situations.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Can leg ulcers be treated?&#8221; tab_id=&#8221;1759014887716-648cb14b-00193721-8edc&#8221;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">Can leg ulcers be treated?<\/h2>\n<p>Yes, leg ulcers can be treated but the best form of treatment for your leg ulcer will depend on exactly why the ulcer has occurred.<\/p>\n<p><strong>Venous ulcers<br \/>\n<\/strong>Some ulcers are clearly caused by problems in the veins.\u00a0 This should be confirmed by clinical assessment and on special investigations.\u00a0 If this is the case then compression treatment should be commenced.\u00a0 It should only be applied after the arteries have been assessed by measuring the ankle-brachial index.\u00a0 This is because if compression is applied and the arteries are badly diseased, this can damage the ulcer and the leg, and make matters worse.\u00a0 It would also be very painful.<\/p>\n<p>Before compression is applied, the leg and the ulcer should be thoroughly cleaned and a simple dry, non-adherent dressing applied to the ulcer itself.\u00a0 The ankle circumference is then measured and the compression system selected.\u00a0 The formal compression bandage is applied by a trained practitioner, usually a nurse skilled in bandaging techniques.\u00a0 The first layer consists of a soft wool bandage to protect bony points at the ankle and the shin bone.\u00a0 A crepe bandage is applied as the second layer.\u00a0 The third layer is an elasticated bandage that will apply compression.\u00a0 The final fourth layer applies further compression and keeps all of the bandages in place.\u00a0 Although this sounds quite complicated it is quite straightforward to apply in practice, by properly trained personnel.\u00a0 These bandages may be left in place for up to 7 days, but should be changed if fluid from the ulcer soaks through the bandages.\u00a0 If possible they are left, as it is thought that each dressing change damages some of the ulcer tissue that is trying to heal.\u00a0 This system is known as 4 layer compression (see opposite) and can be tailored to a certain extent to suit the particular shape and size of leg. In this\u00a0<a href=\"http:\/\/www.nhs.uk\/conditions\/leg-ulcer-venous\/Pages\/Introduction.aspx\" target=\"_blank\" rel=\"noreferrer noopener\">link<\/a>\u00a0a nurse explains some of the features and treatment required for leg ulcers.<\/p>\n<figure id=\"attachment_115\" aria-describedby=\"caption-attachment-115\" style=\"width: 198px\" class=\"wp-caption alignnone\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-115\" src=\"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/wp-content\/uploads\/2025\/10\/Compression-bandages-.jpg\" alt=\"Compression bandages\" width=\"198\" height=\"141\" \/><figcaption id=\"caption-attachment-115\" class=\"wp-caption-text\">Compression bandages<\/figcaption><\/figure>\n<p>Using these techniques it has been shown that 50-70% of pure venous ulcers heal within 12 weeks. A recent randomised trial has compared 4 layer bandaging with conventional ulcer treatments. There was a significant improvement in healing in the 4 layer bandaging group with 54% of ulcers healed at 3 months compared with only 34% in the control group without compression (O\u2019Brien JF et al, 2003). Others may heal after this time depending on their size. If the ulcer fails to respond or the patient is unable to initially tolerate compression then a period of bedrest and elevation of the leg in hospital can be helpful. This usually requires a stay of some weeks. Bedrest helps by reducing swelling in the leg and therefore the amount of fluid passing across the ulcer bed. Compression can usually then be applied to maintain the effect when the patient is discharged.<\/p>\n<p>Although the 4 layer system is one of the most common and effective in modern use, there are alternatives. A recent trial from St Thomas\u2019 Hospital in London compared 3 layer paste bandages with the conventional 4 layer system (Meyer FJ et al, 2003). In this study the 3 layer system was found to be more effective at healing than the 4 layer system. At the very least it is probably comparable and could certainly be used effectively in patients with intolerance to the standard 4 layer regime<\/p>\n<p>Despite intensive treatment there will still be some patients who are left with intractable ulcers that fail to heal. In these circumstances the aim of treatment is to keep the ulcer under control and reduce its\u2019 effect on the day to day life of the patient as much as possible.<\/p>\n<p><strong>Arterial ulcers<\/strong><br \/>\nSome ulcers are mainly arterial even if they have a venous component. This is always the case when the Ankle-Brachial Index is less than 0.5, indicating a severe degree of arterial impairment. In these circumstances compression should never be applied. These ulcers should be managed by examining the arteries in more detail by ultrasound and angiography. Usually patients with these ulcers will require some treatment to improve the blood supply if their ulcer is going to heal.<\/p>\n<p><strong>Mixed ulcers<\/strong><br \/>\nIn some patients the ulcers are caused by a combination of problems in the arteries and the veins. It can sometimes be difficult in these patients to decide the most effective way of managing their ulcer. In general if the Ankle-Brachial Index is greater than 0.5, but less than 0.8, it is often sensible to try modified (lighter) compression as a first option. If this is tolerated and appears to be helping the ulcer to heal, then it should be continued. If it is not tolerated or appears to be unhelpful then it will be important to investigate the arteries in the same way as for arterial ulcers (Humphreys ML, 2007).<\/p>\n<p><strong>General<\/strong><\/p>\n<p>Although ulcers may have predominantly venous or arterial components, there are usually many factors that contribute to the development of an ulcer. The common factors are obesity, immobility, ankle and leg swelling from other causes and poor ankle movements.<\/p>\n<p><strong>Ulcer dressings and antibiotics<\/strong><\/p>\n<p>In general provided the blood supply to the tissues is good and compression is applied, when appropriate, it hardly matters which dressing is placed onto the ulcer bed. As long as it is clean, dry and non-adherent the ulcer should respond. Many claims are made for different types of dressings, most of which are hard to substantiate. Regular changes of dressing type usually have little value and may actually do harm as patients often develop allergic reactions (dermatitis). A recent review and meta-analysis of dressings for venous ulcers showed that the type of dressing applied beneath compression was not shown to influence healing (Palfreyman S, Nelson EA, Michaels JA, 2007). Dressings for venous leg ulcers: systematic review and meta-analysis Objective: To review the evidence of effectiveness of dressings applied to venous leg ulcers. Design: Systematic review and meta-analysis. Results: The search strategy identified 254 studies; 42 of these fulfilled the inclusion criteria. Hydrocolloids were no more effective than simple low adherent dressings used beneath compression (eight trials; relative risk for healing with hydrocolloid 1.02, 95% confidence interval 0.83 to 1.28). For other comparisons, insufficient evidence was available to allow firm conclusions to be drawn. None of the dressing comparisons showed evidence that a particular class of dressing healed more ulcers. Some differences existed between dressings in terms of subjective outcome measures and ulcer healing rates. The results were not affected by the size or quality of trials or the unit of randomisation. Insufficient data were available to allow conclusions to be drawn about the relative cost effectiveness of different dressings. Conclusions: The type of dressing applied beneath compression was not shown to affect ulcer healing. The results of the meta-analysis showed that applying hydrocolloid dressings beneath compression produced no benefit in terms of ulcer healing compared with applying simple low adherent dressings. No conclusive recommendations can be made as to which type of dressing is most cost effective. Decisions on which dressing to apply should be based on the local costs of dressings and the preferences of the practitioner or patient.<\/p>\n<p>Moist wound healing has become the mantra amongst wound \u201cspecialists\u201d. There is probably nothing fundamentally wrong with moist wound healing but the evidence supporting this approach is not good.<\/p>\n<p>There are many dressings popularly thought to aid ulcer healing. Manuka honey has recently been subject to a randomised trial in which 368 patients with leg ulcers were randomised to either conventional care or dressing impregnated with manuka honey. Honey dressings did not improve venous ulcer healing at 12 weeks and may have increased the number of adverse events (Jull et al 2008). Small pilot studies by dressing manufacturers may often demonstrate benefits from a new type of dressing. Subsequent independent studies with improved design and larger numbers of patients usually find most products to be ineffective or no better than the simplest dressings. A particular case in point is the VULCAN trial which examined silver donating dressings. This trial found no benefit in the use of silver dressings for venous leg ulcers but increased costs were incurred. In New Zealand Kawakawa leaves are also thought to be of benefit, but there is no scientific evidence to support their use.<\/p>\n<p>Antibiotics are also frequently prescribed for ulcers on the basis of a swab result that has grown bacteria. Antibiotics should only be used when there is frank infection. This usually means a hot, red, tender leg. Because we are all covered with bacteria a swab taken from anywhere on the body whether ulcerated or not will grow bacteria, but they do not require treatment. They are a normal part of the body flora and the presence of these normal bacteria is known as colonisation. Overtreatment with antibiotics is likely to lead to problems with antibiotic resistance developing in bacteria that are present, making the future treatment of infection even more difficult.<\/p>\n<p><strong>Cleaning your leg<\/strong><\/p>\n<p>It is perfectly acceptable to clean your leg and ulcer with ordinary tapwater. There is no benefit in using sterile water or saline. If you have a planned visit from the district nurse then, by arrangement, it can be useful to shower and clean the leg, if your are able, prior to the planned visit. Only do this after discussion.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;What is the place of venous surgery?&#8221; tab_id=&#8221;1759351148653-52fa9b8b-bcd8&#8243;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">What is the place of venous surgery?<\/h2>\n<p>In patients with venous ulcers (ulcers caused by venous disease only) there is abnormal reverse flow (reflux) in the veins.\u00a0 Colour flow Duplex ultrasound scanning can accurately identify the sites of reflux in the majority of patients.\u00a0 The scan is a painless procedure which takes about 30 minutes for one leg.\u00a0 Following a scan there are 4 main categories of results:<\/p>\n<p><strong>1. Superficial venous reflux only<\/strong>\u00a0\u2013 this situation is potentially correctable by surgery or other therapies that destroy the abnormal superficial veins.\u00a0 There is good evidence that correcting the abnormal reflux will reduce the risk of recurrence (see ESCHAR study below).<\/p>\n<p><strong>2. Deep venous reflux only \u2013\u00a0<\/strong>this situation is not correctable by surgery and the mainstay of treatment is continued compression.\u00a0 Operations to repair the valves in the veins have been devised, but are only performed by a few surgeons worldwide.\u00a0 Although early results often appear good in the hands of individuals, they are often difficult to reproduce.\u00a0 Newer techniques to implant valves using endovascular techniques will need thorough investigation before they can be recommended.<\/p>\n<p><strong>3. Mixed superficial and deep venous reflux \u2013\u00a0<\/strong>the ESCHAR study has now confirmed that with longer follow up surgery to correct the reflux in the superficial veins will benefit these patients.\u00a0 The surgery can easily be performed, but even if successful in eliminating superficial reflux will still leave the patient with uncorrectable deep venous reflux.<\/p>\n<p>4.\u00a0<strong>Occluded deep venous system \u2013<\/strong>\u00a0sometimes after a deep venous thrombosis the vein will not be re-opened by the repair mechanisms of the body and will remain blocked.\u00a0 When this happens the superficial veins can become enlarged to compensate and carry blood back to the heart.\u00a0 If this is the case the superficial varicose veins should not be removed except after detailed assessment under a specialised vascular surgeon.<\/p>\n<p>These are the main categories, although there are many different possible combinations and detailed discussion of the surgical options should take place with your specialist surgeon.\u00a0 It is important to remember that in patients with ulcers the indication for surgery is to reduce the risk of further ulceration and to facilitate healing of pre-existing ulcers by eliminating reflux in the veins.\u00a0 Cosmetic benefits may also be apparent, but this is not the primary aim of surgery.<\/p>\n<p>The ESCHAR study (<a href=\"http:\/\/www.bmj.com\/content\/335\/7610\/83.pdf+html\" target=\"_blank\" rel=\"noreferrer noopener\">Gohel MS, Barwell JR, Taylor M et al.<\/a>), has reported final results on healing and recurrence rates after treatment with compression with or without the addition of surgery to the veins in people with venous leg ulcers.\u00a0 Leg ulcer healing rates at 3 years were 89% for the compression group and 93% for the compression plus surgery group.\u00a0 Rates of ulcer recurrence at 4 years were 56% for the compression group and 31% for the compression plus surgery group. For patients with isolated superficial venous reflux, recurrence rates at 4 years were 51% for compression and only 27% for compression plus surgery.\u00a0 Results were similar in patients with superficial and segmental deep venous reflux (52% versus 24%) at three years.\u00a0 In patients with superficial and total deep venous reflux, there was still benefit from superficial venous surgery with leg ulcer recurrence rates improved from 46% with compression alone, to 32% with the addition of surgery.\u00a0 The authors concluded that most patients with chronic venous ulceration will benefit from the addition of simple venous surgery to reduce ulcer recurrence rates.<\/p>\n<p>In the study overall, 40% of patients refused to undergo venous surgery and this is a reflection of the elderly and infirm population that often presents with leg ulceration. Less invasive treatments now available may offer benefits to this group of patients.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Will I get more leg ulcers?&#8221; tab_id=&#8221;1759351199141-6ce7a83c-4226&#8243;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">Will I get more leg ulcers?<\/h2>\n<p>It is possible to develop further leg ulcers and the risk varies from study to study. Probably between 5-30% of patients will develop further leg ulceration in the first 2 years after ulcer healing. Once ulcers have healed Class 2 below knee compression stockings should be worn. These stockings provide maximum compression at the ankle and this gradually reduces up the leg.\u00a0 Precise measurements of the leg are required to fit the stockings correctly and 2 pairs should be provided so that one can be washed at any one time.\u00a0 The stockings should be replaced approximately every 6 months.\u00a0Compliance with wearing stockings is notoriously poor except where dedicated nurses review patients regularly.<\/p>\n<p>In patients who wear their stockings regularly, recurrent ulceration can be reduced to 32% at 5 years from 69% in patients who do not wear their stocking. Unfortunately there is no definitive trial of compression versus no compression\u00a0<a href=\"http:\/\/onlinelibrary.wiley.com\/store\/10.1002\/14651858.CD002303.pub2\/asset\/CD002303.pdf?v=1&amp;t=hdtfjahd&amp;s=2c4226c6976021744a94b5f964ae69d563809360\" target=\"_blank\" rel=\"noreferrer noopener\">(Nelson et al 2012<\/a>) but most experts would recommend using the highest compression stockings tolerated on a permanent basis.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Community leg ulcer clinics&#8221; tab_id=&#8221;1759351260746-e690e710-a804&#8243;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">Community leg ulcer clinics<\/h2>\n<p>The majority of patients with leg ulcers can be managed in the community by competently trained nurses working to set protocols. The most appropriate model of care for these patients appears to be one consisting of a series of strategically placed community leg ulcer clinics staffed by suitably trained nurses and supported by vascular surgery. Chronic leg ulcer is perfectly suited to shared care with a blend of hospital based specialist intervention and community based care.<\/p>\n<p>Leg ulcer clinics based in the community have been shown in a UK study to provide more clinically effective and cost effective care when compared with traditional home based care delivered by district nurses. New Zealand, however, is not the UK and has a significant rural population often long distances from the nearest town. Despite this there is no doubt that patients report better dressings and improved outcomes from a group of nurses who perform compression bandaging in specialist clinics. This is because they see the same patients frequently and are able to learn to optimise their bandaging technique to provide the best outcome. Dedicated follow up by the same nurses achieves the best results. Too often patients report that they never have the same nurse twice to change the dressing and consequently it is difficult for those nurses to develop their technique in isolation with no feedback.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;Useful links&#8221; tab_id=&#8221;1759014929506-4e94bf49-783d3721-8edc&#8221;][vc_column_text css=&#8221;&#8221;]\n<h2 class=\"wp-block-heading\">Useful links<\/h2>\n<p><a href=\"http:\/\/www.nhmrc.gov.au\/_files_nhmrc\/publications\/attachments\/ext003_venous_leg_ulcers_aust_nz_0.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/www.nhmrc.gov.au\/_files_nhmrc\/publications\/attachments\/ext003_venous_leg_ulcers_aust_nz_0.pdf \u2013\u00a0<\/a>Australian and New Zealand comprehensive guidelines on leg ulcer management<\/p>\n<p><a href=\"http:\/\/www.nhs.uk\/conditions\/leg-ulcer-venous\/Pages\/Introduction.aspx\">http:\/\/www.nhs.uk\/conditions\/leg-ulcer-venous\/Pages\/Introduction.aspx<\/a><\/p>\n<p><a href=\"http:\/\/www.worldwidewounds.com\/2001\/march\/Vowden\/Doppler-assessment-and-ABPI.html\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/www.worldwidewounds.com\/2001\/march\/Vowden\/Doppler-assessment-and-ABPI.html<\/a>\u00a0\u2013 Very detailed site on Dopplers and ABI measurements<\/p>\n<p><a href=\"http:\/\/www.worldwidewounds.com\/1997\/september\/Thomas-Bandaging\/bandage-paper.html\">http:\/\/www.worldwidewounds.com\/1997\/september\/Thomas-Bandaging\/bandage-paper.html<\/a><\/p>\n<p><a href=\"http:\/\/www.medicine.ox.ac.uk\/bandolier\/booth\/painpag\/Chronrev\/Other\/CP105.html\">http:\/\/www.medicine.ox.ac.uk\/bandolier\/booth\/painpag\/Chronrev\/Other\/CP105.html<\/a><\/p>\n<p><a href=\"http:\/\/www.medicine.ox.ac.uk\/bandolier\/booth\/alternat\/AT132.html\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/www.medicine.ox.ac.uk\/bandolier\/booth\/alternat\/AT132.html<\/a>\u00a0<a href=\"http:\/\/www.biomedcentral.com\/1471-2261\/1\/5\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/www.biomedcentral.com\/1471-2261\/1\/5<\/a><\/p>\n<p><a href=\"http:\/\/faculty.washington.edu\/momus\/PB\/chronicv.htm\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/faculty.washington.edu\/momus\/PB\/chronicv.htm<\/a>\u00a0<a href=\"http:\/\/www.worldwidewounds.com\/Common\/ArticleIndex.html\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/www.worldwidewounds.com\/Common\/ArticleIndex.html<\/a><\/p>\n<p><a href=\"http:\/\/en.wikipedia.org\/wiki\/Venous_ulcer\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/en.wikipedia.org\/wiki\/Venous_ulcer<\/a>\u00a0<a href=\"http:\/\/dermnetnz.org\/site-age-specific\/leg-ulcers.html\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/dermnetnz.org\/site-age-specific\/leg-ulcers.html<\/a><\/p>\n<p><a href=\"http:\/\/www.rcn.org.uk\/development\/practice\/clinicalguidelines\/venous_leg_ulcers\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/www.rcn.org.uk\/development\/practice\/clinicalguidelines\/venous_leg_ulcers<\/a>\u00a0<a href=\"http:\/\/emedicine.medscape.com\/article\/1085412-overview\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/emedicine.medscape.com\/article\/1085412-overview<\/a><\/p>\n<p><a href=\"http:\/\/www.vascularweb.org\/vascularhealth\/Pages\/chronic-venous-insufficiency.aspx\">http:\/\/www.vascularweb.org\/vascularhealth\/Pages\/chronic-venous-insufficiency.aspx<\/a><\/p>\n<p><a href=\"https:\/\/en.wikipedia.org\/wiki\/Atherosclerosis\" target=\"_blank\" rel=\"noopener\">http:\/\/en.wikipedia.org\/wiki\/Atherosclerosis<\/a>[\/vc_column_text][\/vc_tta_section][vc_tta_section title=&#8221;References&#8221; tab_id=&#8221;1759015003224-6e58c0d1-e0df3721-8edc&#8221;][vc_column_text css=&#8221;&#8221;]\n<h2>References<\/h2>\n<p><a href=\"http:\/\/www.medicine.wisc.edu\/~williams\/chronic_venous_disease.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Bergan JJ et al. Chronic venous disease<\/a>\u00a0N Engl J Med 2006; 355: 488-98.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2023874\/pdf\/nihms28091.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Criqui MH et al. Risk factors for chronic venous disease: The San Diego population study.\u00a0<\/a>J Vasc Surg 2007; 46: 331-337.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/7718464\" target=\"_blank\" rel=\"noreferrer noopener\">Douglas WS, Simpson NB. Guidelines for the management of chronic venous leg ulceration. Report of a multidisciplinary workshop.<\/a>\u00a0Brit J Dermatol 1995; 132: 446-452.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/8944433\" target=\"_blank\" rel=\"noreferrer noopener\">Grabs AJ, Wakely MC, Nyamekye I, Ghauri ASK, Poskitt KR. Colour duplex ultrasonography in the rational management of chronic venous leg ulcers.<\/a>\u00a0Brit J Surg 1996; 83: 1380-1382.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/9117300\" target=\"_blank\" rel=\"noreferrer noopener\">Scriven JM, London NJM. Single-visit venous ulcer assessment clinic: the first year.\u00a0<\/a>Brit J Surg 1997; 84: 334-336.<br \/>\nGhauri ASK, Poskitt KR. Single-visit venous ulcer assessment clinic: the first year. Brit J Surg 1997; 84: 1323.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2127398\/pdf\/9302954.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Fletcher A, Cullum N, Sheldon TA. A systematic review of compression treatment for venous leg ulcers.<\/a>\u00a0Brit Med J 1997; 315: 576-580.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC1834977\/pdf\/bmj00310-0023.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Blair SD, Wright DDI, Backhouse CM, Riddle E, McCollum CN. Sustained compression and healing of chronic venous ulcers.<\/a>\u00a0Brit Med J 1988; 297: 1159-1161.<br \/>\n<a href=\"http:\/\/dtb.bmj.com\/content\/38\/4\/28.abstract\" target=\"_blank\" rel=\"noreferrer noopener\">Anonymous. Compression therapy for venous leg ulcers.<\/a>\u00a0Drug and Therapeutics Bulletin 2000; 38(4): 28-31.<br \/>\n<a href=\"http:\/\/www.york.ac.uk\/inst\/crd\/EHC\/ehc34.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">NHS Centre for Reviews and Dissemination. Compression therapy for venous leg ulcers.<\/a>\u00a0Effective healthcare 1997; 3(4): 2-12.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/10383574\" target=\"_blank\" rel=\"noreferrer noopener\">Bello M, Scriven M, Hartshorne T, Bell PRF, Naylor AR, London NJM. Role of superficial venous surgery in the treatment of venous ulceration.<\/a>\u00a0Brit J Surg 1999; 86: 755-759.<br \/>\n<a href=\"http:\/\/www.rima.org\/web\/medline_pdf\/JVascSurg2006Oct444803-8.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Nelson EA, Harper DR, Prescott RJ, Gibson B, Ruckley CV. Prevention of recurrence of venous ulceration: prospective randomised controlled trial over 5 years of class 2 and class 3 elastic compression.<\/a>\u00a0J Vasc Surg 2006; 44: 803-88.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/7600337\" target=\"_blank\" rel=\"noreferrer noopener\">Moffatt CJ, Dorman MC. Recurrence of leg ulcers within a community ulcer service.<\/a>\u00a0J Wound Care 1995; 4: 57-61.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2665573\/pdf\/9492652.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Ruckley CV. Caring for patients with chronic leg ulcer.<\/a>\u00a0Brit Med J 1998; 316: 407-408.<br \/>\n<a href=\"http:\/\/www.bmj.com\/content\/316\/7143\/1487.pdf+html\" target=\"_blank\" rel=\"noreferrer noopener\">Morrell CJ, Walters SJ, Dixon S et al. Cost effectiveness of community leg ulcer clinics: randomised controlled trial.<\/a>\u00a0Brit Med J 1998; 316: 1487-1491.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC1883915\/pdf\/bmj00103-0019.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Moffat CJ, Franks PJ, Oldroyd M et al. Community clinics for leg ulcers and impact on healing.<\/a>\u00a0Brit Med J 1992; 305: 13891392.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/10133878\" target=\"_blank\" rel=\"noreferrer noopener\">Bosanquet N, Franks P, Moffat C et al. Community leg ulcer clinics: cost-effectiveness.<\/a>\u00a0Health Trends 1993; 25(4): 146-148.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2351389\/pdf\/bmj00548-0032.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Simon DA, Freak L, Kinsella A et al. Community leg ulcer clinics: a comparative study in two health authorities.<\/a>\u00a0Brit Med J 1996; 312: 1648-1651.<br \/>\n<a href=\"http:\/\/dtb.bmj.com\/content\/24\/3\/9.abstract\" target=\"_blank\" rel=\"noreferrer noopener\">Anonymous. Dressings for leg ulcers. Drugs and Therapeutics Bulletin.<\/a>\u00a01986; 24(3): 9-12.<br \/>\n<a href=\"http:\/\/www.sign.ac.uk\/pdf\/sign120.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Scottish Intercollegiate Guidelines Network. The care of patients with chronic leg ulcer. A national clinical guideline.<\/a>\u00a0SIGN publication No120; 2010.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/12854102\" target=\"_blank\" rel=\"noreferrer noopener\">O\u2019Brien JF, Grace PA, Perry IJ et al. Randomised clinical trial and economic analysis of four layer compression bandaging for venous ulcers.<\/a>\u00a0Brit J Surg 2003; 90: 794-798.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/12905544\" target=\"_blank\" rel=\"noreferrer noopener\">Meyer FJ, McGuiness CL, Lagattolla NRF, Eastham D, Burnand KG. Randomised clinical trial of three-layer paste and four-layer bandages for venous leg ulcers.<\/a>\u00a0Brit J Surg 2003; 90: 934-940.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/17497654\" target=\"_blank\" rel=\"noreferrer noopener\">Humphreys ML, Stewart AHR, Gohel MS et al.\u00a0 Management of mixed arterial and venous ulcers.<\/a>\u00a0Brit J Surg 2007; 94: 1104-07.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC1939774\/pdf\/bmj-335-7613-res-00244-el.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Palfreyman S, Nelson EA, Michaels JA. Dressings for venous leg ulcers: systematic review and meta-analysis.<\/a>\u00a0 Brit Med J 2007; 335: 244.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/18161896\" target=\"_blank\" rel=\"noreferrer noopener\">Jull A, Walker N, Parag V et al. Randomised clinical trial of honey-impregnated dressings for venous leg ulcers.<\/a>\u00a0Brit J Surg 2008; 95: 175-82.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/19787753\" target=\"_blank\" rel=\"noreferrer noopener\">Michaels JA, Campbell B, King B et al. Randomised controlled trial and cost effectiveness analysis of silver donating antimicrobial dressings for venous leg ulcers (VULCAN trial).<\/a>\u00a0Brit J Surg 2009; 96:1147-56.<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/19787752\" target=\"_blank\" rel=\"noreferrer noopener\">Sultan MJ, McCollum C. Don\u2019t waste money when dressing leg ulcers.<\/a>\u00a0Brit J Surg 2009; 96: 1099-1100.<br \/>\n<a href=\"http:\/\/www.bmj.com\/content\/335\/7610\/83.pdf+html\" target=\"_blank\" rel=\"noreferrer noopener\">Gohel MS, Barwell JR, Taylor M et al.\u00a0 Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR study): randomised controlled trial<\/a>. Brit Med J 2007; 335: 83-89<br \/>\n<a href=\"http:\/\/onlinelibrary.wiley.com\/store\/10.1002\/14651858.CD002303.pub2\/asset\/CD002303.pdf?v=1&amp;t=hdtfjahd&amp;s=2c4226c6976021744a94b5f964ae69d563809360\" target=\"_blank\" rel=\"noreferrer noopener\">Nelson EA, Bell-Syer SE, Cullum NA. Compression for preventing recurrence of venous ulcers.<\/a>\u00a0Cochrane Database Syst Rev 2012 (8).<br \/>\n<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/21604256\" target=\"_blank\" rel=\"noreferrer noopener\">Carradice D, Mazzari FAK, Samuel N, Allgar V, Hatfield J, Chetter IC. Modelling the effect of venous disease on quality of life<\/a>.Brit J Surg 2011;98:1089-1098.[\/vc_column_text][\/vc_tta_section][\/vc_tta_tour][\/vc_column][\/vc_row]\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row full_width=&#8221;stretch_row&#8221; content_placement=&#8221;middle&#8221; equal_height=&#8221;yes&#8221; rtl_reverse=&#8221;yes&#8221; remove_bottom_col_margin=&#8221;true&#8221; columns_right=&#8221;yes&#8221; wpex_bg_color=&#8221;#03a3de&#8221; min_height=&#8221;350px&#8221;][vc_column width=&#8221;1\/2&#8243;][\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text css=&#8221;.vc_custom_1759350475966{padding-top: 20px !important;padding-bottom: 20px !important;}&#8221; color=&#8221;#fefefe&#8221;] Chronic Venous Insufficiency and Leg Ulcers [\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1759015527111{margin-top: 60px !important;}&#8221;][vc_column][vc_tta_tour controls_size=&#8221;md&#8221; active_section=&#8221;1&#8243;][vc_tta_section title=&#8221;Background&#8221; tab_id=&#8221;1759012899351-dcaaabe1-cd5c3721-8edc&#8221;][vc_column_text css=&#8221;&#8221;] Background Chronic venous insufficiency and leg ulcers affect approximately 1-2 people per 1000 of the general population, with approximately 10-20 people per 1000&hellip;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-110","page","type-page","status-publish","hentry","entry","no-media"],"_links":{"self":[{"href":"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/index.php\/wp-json\/wp\/v2\/pages\/110","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/index.php\/wp-json\/wp\/v2\/comments?post=110"}],"version-history":[{"count":4,"href":"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/index.php\/wp-json\/wp\/v2\/pages\/110\/revisions"}],"predecessor-version":[{"id":238,"href":"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/index.php\/wp-json\/wp\/v2\/pages\/110\/revisions\/238"}],"wp:attachment":[{"href":"https:\/\/cmcdeploytwo.co.nz\/vsoanz\/index.php\/wp-json\/wp\/v2\/media?parent=110"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}