Q and A: Venous ulcers with concurrent lymphedema

Cheryl Aaron, PT, DPT, CWS

Venous ulcers account for 70-90 percent of all lower extremity ulcers in the United States. In addition, upwards of one million of these venous patients have concurrent lymphedema. In spite of this staggering statistic, most will heal well with proper assessment and treatment.

There are, however, those few wounds that challenge our skills, and without a solid understanding of the complexities of mixed etiology, we may actually cause harm. Here are the three most commonly asked wound care questions by clinicians…

Q. I routinely use compression on my venous ulcer patients with good success. This week, however, when I removed a four layer compression wrap, my patient had blistered in multiple places. What could have caused this?

Barring any sensitivity to the cast padding layer, the most common reason for blistering under compression is an underlying diagnosis of lymphedema. While venous wounds respond exceptionally well to this type of compression (known as long stretch wraps), lymphedema will worsen.

Long stretch means the wrap is giving constant and continual compression. Fragile lymphedema channels will be cut off from normal flow causing a backup of lymph leading to blisters. Patients with lymphedema should only use short stretch wraps which give compression only when the patient is walking; at rest there is no compression allowing for proper lymphatic drainage.

Q. How can I tell if my patient has lymphedema?

A simple test called the Stemmer Sign is a quick assessment tool. An inability to pinch a fold of skin at the base of the second toe is indicative of lymphedema.

Q. I have tried multiple topical antimicrobials, even those able to kill MRSA and VRE, and still my patient's wound looks dull with no bright, beefy granulation. It has a thin vail of yellow slough throughout the bed. My patient has had this wound for over 10 years. She has good arterial flow, yet compression for over 4 weeks has yielded no result. What could be wrong?

Chronic wounds often develop a biofilm. Biofilms are bacteria and fungi encapsulated in a thick, sticky barrier made of polysaccharides and proteins. These protect the bacteria from external threats and attach it to the wound surface rendering antimicrobials and wound cleansing ineffective. The only way to eliminate them is with low frequency ultrasound treatment or surgical debridement.

Have more questions about venous disease and lymphedema? Get the answers in this FREE 2 hour CE Seminar: Venous Disease & Lymphedema Assessment and Treatment Strategies. BONUS: Get up to 1.8 free CE Hours for watching.

FREE CE: Venous Disease and Lymphedema

This blog was brought to life by PESI speaker Cheryl Aaron, PT, DPT, CWS. Cheryl has over 36 years of hands-on experience in physical therapy and wound care. Her clinical practice, specializing in all aspects of wound care, has encompassed a variety of settings, including: acute care, subacute, long-term care, and private practice. In her current role, she is responsible for the educational and consultation needs for multidisciplinary professionals. She established an advanced wound management program and is responsible for clinical competency within the wound care team for nursing and physical therapy staff.

Topic: Wound Care

Tags: Lymphedema | Venous Ulcers

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