An Introduction To Chronic Wounds

“Chronic wounds deeply impact a person’s quality of life. People experience psychological distress, pain, social isolation, and limited mobility…”

Chronic wounds affect the lives of many and need informed care from healthcare professionals. For this in-depth article, Registered Nurse Jess goes through the most prevalent types of chronic wounds and how they are treated.

Most wounds heal on their own, without any outside intervention. However, chronic wounds don’t follow the body’s usual healing process. They can impact someone’s whole life and severely limit a person’s day-to-day activities. People living with these types of wounds require a holistic and skilled approach from the healthcare professionals caring for them. It’s essential to identify the underlying cause of the wound and take the entire picture of a person’s health into consideration when formulating a treatment plan.

In this article, we’ll look at 3 of the most common types of chronic wounds to develop your knowledge and understanding of wound pathophysiology.

Why Wounds Matter

In 2017-18, it was estimated that 3.8 million patients had a wound managed by the NHS, with the annual cost of wound management reaching £8.3 billion.

Chronic wounds deeply impact a person’s quality of life. People experience psychological distress, pain, social isolation, and limited mobility, not to mention an increased chance of infection and complications.

Leg Ulcers: Venous Vs Arterial

The two main causes of leg ulcers are chronic venous insufficiency and peripheral arterial disease. Up to 20% of leg ulcers in elderly patients are of mixed aetiology, meaning they are caused by a combination of venous and arterial disease (ABC, 2022).

Venous

A venous leg ulcer is defined as a break in the skin below the knee, which has not healed within 2 weeks (NICE guidelines). These wounds are caused by venous insufficiency, which occurs due to faulty valves in the veins of the lower legs. These valves prevent the backflow of blood when we are at rest. When they malfunction, the pressure in the veins rises, resulting in venous hypertension. This leads to a chronic inflammatory response, where the skin spontaneously breaks down or is unable to heal after sustaining a minor injury.

Arterial

Arterial leg ulcers are caused by peripheral arterial disease. This is due to atherosclerosis when fatty plaques build up in the arteries causing them to narrow and reduce circulation to the lower extremities. Other causes of arterial ulcers include diabetes, sickle cell disease, thromboangitis and vasculitis (ABC, 2022). Ulceration is often caused by superficial trauma when the body is unable to heal itself due to the lack of oxygen to the tissues.

Chronic wounds deeply impact a person’s quality of life. People experience psychological distress, pain, social isolation, and limited mobility…

Venous Ulcers: Signs And Symptoms

Patients who develop these types of ulcers may have a history of deep vein thrombosis, varicose veins, or venous insufficiency. Other risk factors include obesity, immobility, previous injury or surgery to the leg, increased age, chronic oedema, a history of drug use, or a family history of venous leg ulcers.

It’s likely that before developing a venous leg ulcer, your patient will show signs of venous hypertension. You can learn to recognise the characteristics of venous disease by examining their lower legs for any of the following signs:

- Achy, oedematous legs (pain is often relieved and lessened by elevation)

- Little spider veins around the ankles (known as ‘ankle flare’)

- Varicose veins

- Changes in skin tone and texture, such as woody, hardened skin due to alterations in the dermis and subcutaneous tissue (an inflammatory condition called lipodermatosclerosis)

- A lower leg shaped like an inverted champagne bottle

- Brown discolouration of the skin called haemosiderin, caused by leaking of red blood vessels from the veins into the surrounding tissue

- Red, weeping, scaly, itchy skin called ‘varicose eczema’

- White scarred patches of skin, known as ‘atrophy balance’

Characteristics Of Venous Ulcers

Venous leg ulcers are usually located on the gaiter area, the area of the leg below the knee, and often occur around the malleoli. The wounds are sloping and diffuse, with a high exudate level.

They may be covered in patches of ‘slough’, a type of yellowy/creamy exudate produced by the body’s immune system. The wound bed contains a mixture of this devitalised tissue and healthy red tissue (granulation).

Some people experience pain, usually worse during the dressing change and lessened after elevation. Severe pain is not common and may indicate the presence of infection.

Treatment

There is a common myth that leg ulcers are unable to heal. But it’s very possible for many chronic wounds to heal if a holistic management plan is followed and the wound is regularly reassessed.

The gold standard for treating leg ulcers is compression bandaging. This bandaging uses a graded system to apply pressure at the ankle (about 40mmHg) which gradually reduces up the leg to about 18mmHG just below the knee. Compression helps to reduce superficial venous hypertension and increases venous return to the heart. Different levels of bandaging are available, depending on the arterial health of the lower leg. Venous surgery may be suitable for some people since not everyone is suitable for compression.

Many wounds are managed by Community Nurses, through a process of cleaning and debriding the wound. The aim is to aid healing and prevent infection by using dressings which provide a moist environment and reduce bacterial burden.

However, there’s still a lack of reliable evidence regarding the effectiveness of topical dressings (NICE), and more research needs to be done to prevent excessive waste and costs and improve treatment for patients.

Arterial Ulcers: Signs And Symptoms

In comparison to venous ulcers, arterial wounds differ in their presentation, appearance, and anatomical location. Risk factors include a family history of atherosclerosis, smoking, high cholesterol, diabetes, obesity, hypertension, and a history of vascular complications.

If your patient is suffering from peripheral arterial disease, they may show some of the following symptoms:

- Pain in the lower calf and sometimes thigh and buttock, induced by exercise and relieved by rest (known as intermittent claudication)

- A shiny, hairless lower leg

- Cool peripheries with absent or reduced pedal pulses

- Reduced capillary refill

- Dusky coloured toes and/or feet

- Thickened toenails

Characteristics Of Arterial Ulcers

- Significant pain in the feet and lower legs

- Wounds to the feet, toes, and bony prominences (ABC) that are very difficult to heal

- Wounds located over the toes, feet, and ankles

- Wound with a ‘punched out’ appearance

- Sloughy and/or necrotic tissue in the wound bed

Treatment

Arterial ulcers are not suitable for compression. It’s best practice to perform an ‘ABPI’, also known as a Doppler, as a diagnostic tool to rule out arterial disease before starting compression. This is a type of ultrasound, which is used to identify arterial blood flow, called the Ankle Brachial Pressure Index. ABPI readings fall into 3 main classifications:

>0.8-9=mild arterial disease; 0.5-0.8=mild to moderate; below 0.5 indicates severe arterial disease. If your patient has an ABPI below 0.5, they will require an urgent referral to the vascular team and immediate discontinuation of any compression.

Duplex ultrasounds provide a more detailed picture of the extent of arterial disease, and sometimes angiograms are performed to examine the blood vessels prior to surgical intervention.

Other warning signs for patients requiring immediate surgical intervention are severe pain, gangrene, or debilitating claudication. In the presence of a life-threatening infection or intolerable pain, amputation is necessary. For some people, conservative management will be the preferred choice. This involves regular wound care and assessment in the community, with lifestyle advice and analgesia to manage pain. Dressings can also be used to aid a moist healing environment, absorb excess exudate, and provide protection.

Quote: If you’re interested in wound care, you might even want to consider a role as a Tissue Viability Nurse as a future career choice.

Pressure Damage

A pressure injury occurs as a result of pressure, or pressure in combination with shear, which results in localised damage to the skin and the underlying tissue and skin structures. The damage impairs blood and lymphatic circulation, which results in an inflammatory response at the site of injury.

Pressure injuries develop over bony prominences such as the elbows, sacrum, heels, ankles, hips, knees, back of the neck and thoracic spine. But pressure damage can also occur when a medical device or object is not repositioned regularly, such as nasal cannulae or a neck brace.

The UK follows the SSKIN assessment bundle to aid in the prevention and treatment of pressure ulcers:

-S: Support surface requirements

-S: Skin inspection

-K: Keeping the patient moving

-I: Incontinence and moisture assessment and management

-N: Nutrition and hydration.

How To Treat A Pressure Ulcer

The above assessment covers the main areas that impact skin integrity and/or impede healing.

You might take the following actions following your assessment:

- Offloading pressure using a heel protector to elevate the heels off the bed

- Completing a continence assessment for your patient and ordering appropriate absorbent pads to reduce excess moisture on the skin

- Referring an underweight or malnourished patient to the dietician so they can receive nutritional supplements and dietary support

- Assessing someone for a specialised pressure relieving mattress to help distribute pressure more evenly across the body

Creating a management plan for a pressure ulcer involves taking care of the whole person. You need to consider all the different contributing factors and try to address each one to prevent further harm and injury from occurring.

There is some confusion about how to categorise pressure injuries, especially as guidance differs across various NHS Trusts. But if in doubt, remember the underlying causes of pressure damage and focus on reducing harm to your patient to the very best of your ability.

Where Can You Go From Here?

There are plenty of online resources to help you learn more about chronic wounds. If you work for a trust, check the local policy and training materials for more information.

If you’re interested in wound care, you might even want to consider a role as a Tissue Viability Nurse as a future career choice.

Thanks for reading.