- 1 - Welcome to the ninth edition of the Dressings Times in which Dr Mary Bliss, Consultant Physician in Medicine for the El- derly, Hackney Hospital, puts forward her personal and thought-provoking view of wound management including the treatment of leg ulcers. The second part of her article which deals with the management of pressure sores will form the basis of a future edition of the Dressings Times. THE MANAGEMENT OF LEG ULCERS Perhaps the chief difficulty in writing about dressings and wound management is that few doctors - or even nurses - have experience of all types of wound, or of all types of dressings (an ever increasing variety), so that we tend to rely on hearsay for many of our comments. This is the surest way to promote fashionable rubbish which all too eas- ily then gets into the text books and once there, as the history of medicine shows, is very difficult to remove! An allied and equally important factor is the paucity of properly controlled clinical trials to define the effective- ness of particular applications for different types of wound.1 This is partly because topical applications, unlike drugs, do not usually kill patients if wrongly applied al- though they may cause as much morbidity and distress. An- other reason is that dressings have traditionally been seen as the responsibility of nurses rather than of doctors and so have escaped the vigorous peer scrutiny which has accom- panied the development of modern drugs. More important than all these factors is the sheer difficulty of carrying out meaningful trials of wound healing due to the problems of the relatively low numbers of wounds in any one practice or hospital department, the enormous variation in aetiology and pathology and in the ages and general condition of the pa- tients, the length of time which many ulcers take to heal and the frequency of recurrence and differences in general management - e.g., posture, nutrition, antibiotic therapy. So many factors are involved that to reach any valid conclu- sion about healing techniques requires enormous numbers of subjects beyond the capability of most organisations. Some of the best studies have tried to overcome these prob- lems by creating artificially inflicted wounds of standard size and shape usually in experimental animals2 and occa- sionally in humans.3 Although these wound models have been useful in helping to develop dressings suitable for clean surgical wounds, they may have little relevance for the man- agement of vasculitic or ischaemic ulcers in sick patients. Some workers have tried to create illness, e.g., septi- caemia, vitamin C deficiency,4 in their experimental animals but these are unlikely to represent the complex clinical states underlying the development of lesions such as leg ul- cers and pressure sores and are ethically questionable. Even common procedures such as packing open wounds have not been subjected to scientific assessment. All too often studies promoted primarily by manufacturers have confined themselves to comparing the effects of one product with an- other, e.g., silastic foam as opposed to conventional gauze packing.5 Few studies have attempted to show whether no dressing/application might not be equally effective. Yet probably all trials of a new drug have at some stage includ- ed a group of patients treated with a placebo, i.e., no drug. It is not sufficient to extrapolate the results found in one set of circumstances to others which may be quite different, e.g., a moist environment which has been shown to promote epithelial cell migration and healing in clean, su- perficial wounds2 may not be the best method of dealing with heavily infected or deep necrotic sores, or packing which may be beneficial in preventing recurrence following exci- sion of a pilonidal sinus does not mean that all wounds in the same area, e.g., pressure sores, require the same treat- ment. Any trial of local therapy should include an attempt to standardise the general management of the patient as far as possible. However, this is also very difficult. For exam- ple, it is difficult to regulate, or even measure, the amount of continuing pressure being applied to a pressure sore. A study of dressings for leg ulcers which I once at- tempted in hospital patients quickly ran into difficulties when I unwittingly tried to ensure that all the participants spent the day when they were not walking about, resting on their beds with the foot raised 6 inches. At that time I was not measuring ankle blood pressure and this treatment proved to be an effective way of distinguishing those pa- tients with primarily arterial ulcers by their increased pain and speed of deterioration! Now, although I still try to nurse most patients with foot and leg sores on their beds at least until fluid retention and oedema has been correct- ed, I do not allow the foot to be raised in any elderly pa- tient. About 40% of all leg ulcers have an arterial component6,7 which rises sharply with age. Once oedema has been relieved, patients with predominantly ischaemic foot and leg sores usually do best with the improved blood flow produced with their legs dependent (hanging down). This was brought home to me by an arteriopath with a chronic is- chaemic sore on the lateral border of his foot which I had treated unavailingly by rest on his bed in hospital with different dressings for many weeks. Eventually I had to send him home to the care of his wife and to my surprise and chagrin, he came to the Day Hospital about 2 weeks later with his ulcer almost healed - probably due to his failure to comply with my instructions to keep his foot up and in- creased activity. The equivalent of Buerger's exercises8 - allowing the leg to be dependent for about half of the 24 hours and raised to the horizontal by rest on a bed or sofa for the rest of the time may be the best general management for patients with distal vessel disease (the majority) who cannot be helped by vascular surgery. However, many of these patients will not tolerate any leg elevation and they may be right. Good nutrition and general care are also ex- tremely important. Systemic antibiotics are seldom helpful so that leg ulcers do not usually need to be swabbed unless infection with a pathogen such as B haemolytic streptococcus is suspected because of spreading cellulitis or increased pain. Not only do we lack data about the effectiveness of differ- ent dressings; we do not even know whether nursing immobile patients on their beds, probably the single most important measure in the management of both leg ulcers and pressure sores, increases the incidence of venous thrombosis compared to chair-nursing. As with dressings, nearly all studies of DVT prevention have concentrated on the effects of different aids,9 rather than on the general management of the patient. Elevation of the legs is known to increase venous and capil- lary blood flow10 and at least two professors of surgery be- lieve that the incidence of venous thrombosis in postopera- tive patients is reduced by nursing them in bed11 - `early ambulation equals early angulation'.12 The best policy may be to get patients who are well enough up for meals, walking to the toilet and physiotherapy but to return them to rest on their beds at other times until they are able to stand or move independently. In the absence of conclusive answers to these questions, the best we can do is to observe our pa- tients meticulously and try to act on what we learn from this rather than what is written in textbooks or manufactur- ers' brochures. A leg ulcer clinic in a day hospital for the elderly Recently, inspired by the initiative of the vascular surgery service at Charing Cross Hospital,13 I have tried to be more objective in my assessment of leg ulcers in my elderly pa- tients. We have started a small clinic in the Day Hospital to which my colleagues, GPs and district nurses refer pa- tients with resistant ulcers. Our original aim was to treat as many patients as possible with the 4 layer compression bandaging technique developed at Charing Cross; however, of the 18 patients we have seen so far, only 9 had ankle brachial pressure indices of 0.8 or more in the affected leg and were therefore suitable for compression bandaging. In 4 of these this had to be discontinued within one week and 2 others in between 2 and 8 weeks because of intolerable pain, in most cases associated with visible new necrosis in the ulcer base or extension in area, especially around the malleoli. In 3 of the patients who responded well to ban- daging, ulceration was clearly due to gross oedema associat- ed with heart failure and/obesity and failure to keep their legs elevated at home. Unfortunately, these were unable to tolerate graduated elastic stockings subsequently so that the ulcers rapidly recurred. So far, in the 6 months during which we have been running the clinic, we have only `cured' one ulcer. This was the only varicose ulcer not involving the malleolus in the group and we are now waiting to see if the 84 year old patient will be able to continue to put on her compression stockings. She lives in a Part III residen- tial home but the attendants have already told me that they do not think it is their job to help her and she finds the applicator too complicated. Is it appropriate for us to ask the district nurses to visit her daily to put on a pair of stockings instead of doing a dressing as formerly? These are the realities of leg ulcer management in elderly pa- tients. Other patients in the study have been admitted to hospital for bed-rest, intravenous antibiotic therapy or treatment of pressure sores. The majority have depended on twice weekly dressings in the Day Hospital, sometimes sup- plemented by intermediate visits at home by the district nurse. These are the patients on whom I have gradually been acquiring some limited first hand experience of different dressings. For patients undergoing compression bandaging we use a sim- ple low adherent dressing such as Tricotex (Smith and Nephew) or N-A Dressing (Johnson and Johnson) dressings rec- ommended by the Charing Cross group. These seemed satisfac- tory in the patients who responded. For those unfit for compression bandaging or who did badly, however, other dressings were required. These have included the use of Scherisorb gel (Smith & Nephew) under a semipermeable film such as Tegaderm (3M Healthcare) or Opsite (Smith and Nephew) to debride new necrotic areas, Hydrocolloids such as Granuflex (Convatec) and Alginate dressings such as Kalto- stat (calcium sodium alginate) (Britcair). The most necrot- ic ulcers are dressed with additional odour absorbing dress- ings such as Actisorb Plus (Johnson & Johnson). Although it encouraged healing, we found that after one or two weeks, Granuflex was rejected by the patients because of leakage (much more profuse in patients with resistant ulcers being treated at home who cannot or will not keep their legs ele- vated than in hospital patients) and the associated foul smell which was upsetting their families and social life. Daily dressings would have been impractical and too expen- sive. Kaltostat was also unpopular with patients with heav- ily exuding legs because the resulting gel became `hard' and painful. Again, daily dressing would probably have helped. The smell of very necrotic ulcers has remained a problem not noticeably alleviated by the applica- tion of Actisorb. Several patients have insisted on return- ing to daily dressings of paraffin gauze which they or their wives can carry out themselves. We hope to continue to re- view these patients, however. At least one benefit of this study has been the greatly improved condition of the skin surrounding the ulcers due to the discontinuation of antibi- otic and other types of impregnated tulles and bandages and we would like to maintain this. However, in the light of our failure to heal or to maintain healing in the majority of our patients, even with in-patient treatment, we our- selves have been driven to experimenting, very unsuccessful- ly, with dilute sodium hypochlorite! An interesting observation in this clinic has been the way in which ulcers of all types - varicose, vasculitic, is- chaemic - vary from week to week and how inexplicably and rapidly new ulcers may appear - usually initially as a black infarcted area - without any apparent external trauma. The patients are seldom surprised, having experienced this many times over the years. Callum7 estimates that only 25% of ulcers are active at any one time. Usually the new necrosis appears to coincide with a period of deterioration in the patient's general health, e.g., intermittent diarrhoea in one man. These fluctuations in the activity of the ulcer are another feature which makes the evaluation of dressings so difficult. References 1. Vanden Burg M.J, Regulatory considerations: A paper pre- sented at a conference on `Wound management: varicose ul- cers', Royal Society of Medicine, 1990, 5-6th July. 2. Barnett S.E. and Varley S.J., Occlusion investigated, Care Science and Practice, 1983, 3, (1), 9-12. 3. Buchan I. and Lang S.M., The importance of moisture, Care Science and Practice, 1983, 3, (1), 5-8. 4. Barton A.A. The pathogenesis and inhibition of pressure sores, MD Thesis, London University, 1970. 5. Wood R.A.B., Williams R.H.P. and Hughes L.E., Foam elas- tomer dressing in the management of open granulating wounds: experience with 250 patients, Br. J. Surg., 1977, 64, 554-557. 6. Cornwall J.V. and Lewis J.D., Leg ulcers revisited, Care Science and Practice, 1985, (Special edition). 7. Callam M.J., Ruckley C.V., Harper D.R. and Dale J.J., Chronic ulceration of the leg: extent of the problem and provision of care, Br. Med. J. 1985, 290, 1855-1856. POINTS FROM THE POST Following the last issue of the Dressing Times which con- tained an article on the use of sugar paste in wound manage- ment, we have received several queries as for further infor- mation on the use of this material. A number of people have also asked if the application of the paste could have any adverse effects upon blood glucose levels in diabetics. When taken by the oral route, sucrose, the main ingredient of sugar paste, is broken down to the monosaccharides glu- cose and fructose by enzymes present in the mucosal cells of the small intestine. These are then absorbed and metabolised by the body. Any sucrose which is absorbed un- changed is promptly excreted in the urine. Sucrose injected into the blood stream is also excreted by the same route.1 It follows therefore that if any sugar is absorbed following the topical application of sugar paste, it will not be metabolised or broken down and therefore should have no ef- fect upon blood glucose levels. Consequently, there appears to be no obvious reason why sugar paste should not be use in the management of sloughy or necrotic wounds on diabetic pa- tients. 1. Medical Physiology and Biochemistry, Horrobin D.F., Ed- ward Arnold (Publishers) Ltd. London, 1972. The Dressings Times is produced by the Surgical Materials Testing Laboratory, (SMTL) Bridgend General Hospital, Quarella Road, Bridgend, Mid Glamorgan. Telephone No. (0656) 752820.