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  Table of Contents  
THERAPEUTIC GUIDELINES
Year : 2014  |  Volume : 5  |  Issue : 3  |  Page : 383-385  

Venous leg ulcers: Other treatments


Department of Dermatology, Government Medical College, Director CUTIS Skin Institute, Srinagar, Jammu and Kashmir, India

Date of Web Publication31-Jul-2014

Correspondence Address:
Imran Majid
CUTIS Skin Institute Srinagar Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.137823

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How to cite this article:
Majid I. Venous leg ulcers: Other treatments. Indian Dermatol Online J 2014;5:383-5

How to cite this URL:
Majid I. Venous leg ulcers: Other treatments. Indian Dermatol Online J [serial online] 2014 [cited 2019 Dec 14];5:383-5. Available from: http://www.idoj.in/text.asp?2014/5/3/383/137823


   Electric stimulation Top


Electrical stimulation therapy is believed to simulate the electric current that is generated at the time of injury or breaking down of the skin, thereby stimulating the healing response in the skin and underlying tissues. [1] Electric current has also been shown to increase the migration of neutrophils and macrophages, increase the local blood flow and stimulate the fibroblasts as well. [2],[3]

Various methods of electrical stimulation have been reported in the literature until date for the treatment of venous ulcers or chronic wounds. Electrical stimulation treatment methods range from high voltage to low voltage currents, pulsed to nonpulsed, and alternating to direct currents. [4],[5],[6] Until date, there are no clinical studies to compare the efficacy of these different types of electrical stimulating devices and methods in wound healing.

A number of randomized controlled trials (RCTs) have been conducted on the subject of electrical stimulation therapy in chronic wounds. [7],[8] Majority of these studies have demonstrated a positive effect of the electrical stimulation in the healing of chronic wounds.

As far as venous ulcers are concerned there are a few double-blind randomized trials that have shown a beneficial effect with electrical stimulation therapy (Level B). [9],[10],[11]

Electrical stimulation therapy is generally contraindicated in patients with cardiac arrhythmias such as ventricular arrhythmias or atrial fibrillation, deep venous thrombosis or thrombophlebitis, pregnancy, active osteomyelitis, and patients on pacemakers. [11]


   Conclusions Top


Electrical stimulation therapy can be used as an adjunctive treatment of venous ulcers (Level B).


   Hyperbaric oxygen therapy Top


The proposed mechanism of action of hyperbaric oxygen in management of leg ulcers is through its anti-inflammatory as well as antibacterial effects [12] (Level C). Increase in the oxygen concentration during this treatment is supposed to help in neutrophil dependent microbial killing, collagen cross-linking as well as neovascularization. [13]

Hyperbaric oxygen therapy can be administered in two different ways. One of these is to make the patient breathe 100% oxygen, while exposed to increased atmospheric pressure. The treatment is carried out in chambers meant for single or multiple persons. Exposure is continued for about 1.5-2 h, depending on the indication and the treatment is performed 1-3 times a day. Another method of administering hyperbaric oxygen therapy is by exposing only the affected limb to high oxygen concentration under pressure.

Most of the clinical studies on the efficacy of hyperbaric oxygen therapy in venous ulcers are retrospective and uncontrolled studies. No properly conducted RCT has been conducted on the subject until now except one study involving 16 patients with venous ulcers. The study reported a significant reduction in wound area at 6 weeks after hyperbaric oxygen therapy, but this effect could not be maintained at 18 weeks. Moreover, the study had a high drop-out rate (Level C). [14]

The most important adverse effect that can result from hyperbaric oxygen therapy is central nervous system toxicity that manifests in the form of seizures. [15],[16] Other adverse effects that have been reported include progressive, reversible myopia and irreversible nuclear cataracts. [17],[18]


   Conclusions Top


The efficacy of hyperbaric oxygen therapy in venous ulcers is still not proven beyond doubt. Thus, the therapy can only be recommended as an adjunctive treatment in selected refractory cases of venous leg ulcers (Level C).


   Vacuum assisted closure Top


Vacuum assisted closure (VAC) therapy, also known as negative pressure wound therapy, employs negative pressure to improve the blood flow, decrease local tissue edema, and remove the excessive fluid from the ulcer bed. This is supposed to assist the formation of healthy granulation tissue and also remove the bacterial load from the wound bed (Level C). [19] Another hypothesis proposed is that negative pressure, when used cyclically, alters the cytoskeleton of the cells in the ulcer bed and this triggers the formation of healthy granulation tissue. [20],[21]

Vacuum assisted closure therapy is administered by means of special devices that generate a negative or sub-atmospheric pressure gradient over the area to be treated. [22] Negative pressure is applied either in a continuous or intermittent fashion and the optimal negative pressure employed is in the range of 75-125 mmHg (Level C). Depending upon the size of the ulcer to be treated negative pressure can be applied in a continuous fashion for the first 48 h to remove larger amounts of fluid. [23],[24]

A Cochrane-based review on the efficacy of VAC therapy in chronic wounds listed seven RCTs that were devoid of any bias and other confounding factors. The majority of these studies did mention a positive effect of VAC therapy on chronic wounds, but the review found methodological flaws in most of the studies. Therefore, the review proposed that while trials do demonstrate a beneficial effect of VAC therapy on wound healing, more, better quality research was needed to recommend the treatment option. [25]

Vacuum assisted closure therapy has been associated with an increased risk of thromboembolism and is thus contraindicated in patients with such a tendency. [26]


   Conclusions Top


Although, VAC therapy has been anecdotally used in the management of venous ulcers, there are no definite evidences to support its use in treating this condition (Level C). More research is needed to confirm the positive therapeutic effect of VAC therapy in venous ulcers.


   Laser therapy Top


The mechanism of action of lasers in the management of venous ulcers is not known. The hypothesis that have been postulated are improved metabolism of the affected tissue, [27] stimulation of the tissue repair [28] and increased collagen synthesis. [29] In addition, if the laser is used endovenously, it can lead to occlusion of the treated vein via direct endothelial damage resulting in collagen contraction and fibrosis. [30]

Lasers in venous ulcers are used in two different ways. One-way is to use the laser beam externally over the affected area on the leg and the other way is to pass the laser fiber into the lumen of the affected vein and use the laser beam endovenously.

The efficacy of lasers in management of venous ulcers has not been proven till date. There are a few RCTs on this subject but the data obtained from these trials has not been convincing [31],[32],[33],[34] (Level C). Some other isolated case series and nonrandomized trials have also been conducted with similar results. [35],[36],[37]


   Conclusions Top


While there are reports of a beneficial effect of using lasers in the management of venous ulcers, the evidence is not convincing enough to recommend the treatment modality routinely in venous ulcers (Evidence Level C).

 
   References Top

1.Fitzgerald GK, Newsome D. Treatment of a large infected thoracic spine wound using high voltage pulsed monophasic current. Phys Ther 1993;73:355-60.  Back to cited text no. 1
    
2.Hecker B, Carron H, Schwartz DP. Pulsed galvanic stimulation: Effects of current frequency and polarity on blood flow in healthy subjects. Arch Phys Med Rehabil 1985;66:369-71.  Back to cited text no. 2
[PUBMED]    
3.Bourguignon GJ, Bourguignon LY. Electric stimulation of protein and DNA synthesis in human fibroblasts. FASEB J 1987;1:398-402.  Back to cited text no. 3
    
4.Kloth LC, Feedar JA. Acceleration of wound healing with high voltage, monophasic, pulsed current. Phys Ther 1988;68:503-8.  Back to cited text no. 4
    
5.Gault WR, Gatens PF Jr. Use of low intensity direct current in management of ischemic skin ulcers. Phys Ther 1976;56:265-9.  Back to cited text no. 5
[PUBMED]    
6.Gardener SE, Frantz RA, Schmidt FL. Effect of electrical stimulation on chronic wound healing: a meta analysis. Wound Repair and Regeneration 1999;7:495-503.  Back to cited text no. 6
    
7.Wolcott LE, Wheeler PC, Hardwicke HM, Rowley BA. Accelerated healing of skin ulcer by electrotherapy: Preliminary clinical results. South Med J 1969;62:795-801.  Back to cited text no. 7
[PUBMED]    
8.Wood JM, Evans PE 3 rd , Schallreuter KU, Jacobson WE, Sufit R, Newman J, et al. A multicenter study on the use of pulsed low-intensity direct current for healing chronic stage II and stage III decubitus ulcers. Arch Dermatol 1993;129:999-1009.  Back to cited text no. 8
    
9.Houghton PE, Kincaid CB, Lovell M, Campbell KE, Keast DH, Woodbury MG, et al. Effect of electrical stimulation on chronic leg ulcer size and appearance. Phys Ther 2003;83:17-28.  Back to cited text no. 9
    
10.Stiller MJ, Pak GH, Shupack JL, Thaler S, Kenny C, Jondreau L. A portable pulsed electromagnetic field (PEMF) device to enhance healing of recalcitrant venous ulcers: A double-blind, placebo-controlled clinical trial. Br J Dermatol 1992;127:147-54.  Back to cited text no. 10
    
11.Katelaris PM, Fletcher JP, Little JM, McEntyre RJ, Jeffcoate KW. Electrical stimulation in the treatment of chronic venous ulceration. Aust N Z J Surg 1987;57:605-7.  Back to cited text no. 11
    
12.Kranke P, Bennett M, Roeckl-Wiedmann I, Debus S. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev 2004.  Br J Surg 2005;92:24-32.  Back to cited text no. 12
    
13.Goldman RJ. Hyperbaric oxygen therapy for wound healing and limb salvage: A systematic review. PM R 2009;1:471-89.  Back to cited text no. 13
    
14.Hammarlund C, Sundberg T. Hyperbaric oxygen reduced size of chronic leg ulcers: A randomized double-blind study. Plast Reconstr Surg 1994;93:829-33.  Back to cited text no. 14
    
15.Davis JC, Dunn JM, Heimbach RD. Hyperbaric medicine: Patient selection, treatment procedures, and side-effects. In: Davis JC, Hunt TK, editors. Problem Wounds. New York: Elsevier; 1988. p. 225-35.  Back to cited text no. 15
    
16.Plafki C, Peters P, Almeling M, Welslau W, Busch R. Complications and side effects of hyperbaric oxygen therapy. Aviat Space Environ Med 2000;71:119-24.  Back to cited text no. 16
    
17.Lyne AJ. Ocular effects of hyperbaric oxygen. Trans Ophthalmol Soc U K 1978;98:66-8.  Back to cited text no. 17
    
18.Palmquist BM, Philipson B, Barr PO. Nuclear cataract and myopia during hyperbaric oxygen therapy. Br J Ophthalmol 1984;68:113-7.  Back to cited text no. 18
    
19.Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: A new method for wound control and treatment: Animal studies and basic foundation. Ann Plast Surg 1997;38:553-62.  Back to cited text no. 19
    
20.Hartnett JM. Use of vacuum-assisted wound closure in three chronic wounds. J Wound Ostomy Continence Nurs 1998;25:281-90.  Back to cited text no. 20
    
21.Argenta LC, Morykwas MJ. Vacuum-assisted closure: A new method for wound control and treatment: Clinical experience. Ann Plast Surg 1997;38:563-76.  Back to cited text no. 21
    
22.Kalailieff D. Vacuum-assisted closure: Wound care technology for the new millennium. Perspectives 1998;22:28-9.  Back to cited text no. 22
    
23.Greer SE, Duthie E, Cartolano B, Koehler KM, Maydick-Youngberg D, Longaker MT. Techniques for applying subatmospheric pressure dressing to wounds in difficult regions of anatomy. J Wound Ostomy Continence Nurs 1999;26:250-3.  Back to cited text no. 23
    
24.Moisidis E, Heath T, Boorer C, Ho K, Deva AK. A prospective, blinded, randomized, controlled clinical trial of topical negative pressure use in skin grafting. Plast Reconstr Surg 2004;114:917-22.  Back to cited text no. 24
    
25.Ubbink DT, Westerbos SJ, Evans D, Land L, Vermeulen H. Topical negative pressure for treating chronic wounds. Cochrane Database Syst Rev 2008 ;3:1-34.  Back to cited text no. 25
    
26.Leijnen M, Steenvoorde P, van Doorn L, Zeillemaker AM, da Costa SA, Oskam J. Does VAC increase the risk of venous thromboembolism? J Wound Care 2007;16:211-2.  Back to cited text no. 26
    
27.Basford JR. Low intensity laser therapy: Still not an established clinical tool. Lasers Surg Med 1995;16:331-42.  Back to cited text no. 27
    
28.Abergel RP, Lyons RF, Castel JC, Dwyer RM, Uitto J. Biostimulation of wound healing by lasers: Experimental approaches in animal models and in fibroblast cultures. J Dermatol Surg Oncol 1987;13:127-33.  Back to cited text no. 28
    
29.Germain L, Jean A, Auger FA, Garrel DR. Human wound healing fibroblasts have greater contractile properties than dermal fibroblasts. J Surg Res 1994;57:268-73.  Back to cited text no. 29
    
30.Huang Y, Jiang M, Li W, Lu X, Huang X, Lu M. Endovenous laser treatment combined with a surgical strategy for treatment of venous insufficiency in lower extremity: A report of 208 cases. J Vasc Surg 2005;42:494-501.  Back to cited text no. 30
    
31.Bihari I, Mester AR. The biostimulative effect of low level laser therapy of long-standing crural ulcers using helium neon laser, helium neon plus infrared lasers, and noncoherent light: Preliminary report of a randomized double-blind comparative study. Laser Ther 1989;1:97-8.  Back to cited text no. 31
    
32.Malm M, Lundeberg T. Effect of low power gallium arsenide laser on healing of venous ulcers. Scand J Plast Reconstr Surg Hand Surg 1991;25:249-51.  Back to cited text no. 32
    
33.Lundeberg T, Malm M. Low-power HeNe laser treatment of venous leg ulcers. Ann Plast Surg 1991;27:537-9.  Back to cited text no. 33
    
34.Crous L, Malherbe C. Laser and ultraviolet light irradiation in the treatment of chronic ulcers. Physiotherapy 1988;44:73-7.  Back to cited text no. 34
    
35.Flemming KA, Cullum NA, Nelson EA. A systematic review of laser therapy for venous leg ulcers. J Wound Care 1999;8:111-4.  Back to cited text no. 35
    
36.Lagan KM, McKenna T, Witherow A, Johns J, McDonough SM, Baxter GD. Low-intensity laser therapy/combined phototherapy in the management of chronic venous ulceration: A placebo-controlled study. J Clin Laser Med Surg 2002;20:109-16.  Back to cited text no. 36
    
37.Kopera D, Kokol R, Berger C, Haas J. Does the use of low-level laser influence wound healing in chronic venous leg ulcers? J Wound Care 2005;14:391-4.  Back to cited text no. 37
    




 

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