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Leg ulcer - venous - Management
When should I refer someone with a venous leg ulcer?

  • All people should be managed by a healthcare professional who is trained in the management of venous leg ulcers.
  • Many primary care teams will have expertise in managing venous leg ulcers via appropriately trained practice nurses or district nurses. A referral to other services (secondary care) is often only necessary if there is an uncertain diagnosis, or a person does not respond to treatment in primary care, or complications develop.
  • Refer a person to secondary care before treatment if there is:
    • An uncertain diagnosis.
    • A suspected alternative cause of ulceration:
      • Arterial or mixed venous/arterial ulcer: refer people with an ankle brachial pressure index (ABPI) of less than or equal to 0.8 to a specialist vascular clinic for further assessment of arterial disease. If the ABPI is less than 0.5, refer urgently.
      • Suspected malignant ulcer, rapidly deteriorating ulcer, an atypical appearance or distribution of ulcers — refer to Dermatology for possible biopsy.
      • An ulcer associated with rheumatoid arthritis, or ulcers associated with systemic vasculitis.
      • An ulcer associated with diabetes mellitus, or the person has newly diagnosed diabetes mellitus.
  • Refer a person to secondary care during treatment if there is:
    • A complication related to the ulcer or treatment:
      • Suspected contact dermatitis — refer to Dermatology for patch testing using a leg ulcer series.
      • Cellulitis requiring intravenous antibiotics or cellulitis worsening despite treatment.
      • Pain which is uncontrolled — refer to a specialist pain team.
    • A non-healing or worsening ulcer after 2–3 months of standard treatment.
    • A Recurrent ulcer.
    • A condition which needs specialist assessment and intervention such as varicose veins or arterial insufficiency.
Basis for recommendation
  • These recommendations are based on clinical guidelines The nursing management of patients with venous leg ulcers published by the Royal College of Nursing (RCN) [RCN, 2006], and the Scottish Intercollegiate Guidelines Network guideline Management of chronic venous leg ulcers [SIGN, 2010], together with the best available trial evidence, informed expert opinion, and current good clinical practice.
  • A co-ordinated multidisciplinary team approach is vital, as a variety of healthcare professionals including practice nurses, district nurses, general practitioners, dermatology specialist nurses and teams, and vascular teams may be involved. Direct access to specialized hospital services is vital in the management of specific complications.
  • The RCN guideline found no studies that specifically examined the outcomes of people with leg ulcers referred from primary to secondary care, or between healthcare professionals in primary care. The recommendations are therefore largely based on expert opinion [RCN, 2006].
  • Community leg ulcer clinics may significantly improve healing and recurrence rates, and are more cost effective when they have close liaison with secondary care [NHS CRD, 1997; SIGN, 2010].
  • Leg ulcer nurse specialists in dedicated clinics can promote and maintain standards of care and cost effectiveness [Simon et al, 2004].
  • The incidence of contact allergy increases with the duration of ulceration, and several large patch test studies have shown that the principal sensitizers are ingredients of applications, dressings, and bandages [SIGN, 2010].

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