Venous revenge - trophic ulcers

Our expert ALEKSANDRA KUŠPELO, surgeon at Health Center 4, wound specialist

Treating trophic ulcers is difficult - the patient has to reckon not only with a long period during which bandages will have to be changed regularly - and compression socks must be obediently worn, but also with expenses and the need to call relatives and friends to help.

It is known that the society is aging, but people do not want to lose the quality of life with age. A modern eighty-year-old can still be very active, wants to travel, work in the garden. Many people at this age have various diseases - heart failure, diabetes, connective tissue diseases. Trophic ulcers are also a disease of older people rather than young people, which can be closely related to other diseases, but can reduce the quality of life much more.

"You can't talk only about trophic ulcers, you have to talk about people," the experienced doctor Alexandra Kušpelo emphasizes the importance of individual care.

How ulcers form

Ulcers do not appear in one or two days, but over a longer period of time. Before that, swelling of the legs heralds the impending danger. "For example, a person with heart failure sits for a long time on the sofa, legs lowered, crossed, swollen. Another sits at the table, bent to one side, and then wonders why exactly the left or right leg is swollen. The explanation - the spine is crooked, in the small pelvis, all the organs are compressed, the vein on the relevant side is compressed, blood flow is disturbed, the heart does not pump as it should," the doctor describes.

Doctors usually prescribe diuretics for edema, but many do not want to use them. "Running to the toilet is bothersome. No one likes that! For example, the janitor who should take diuretic medicine at five in the morning, but she has to work, doesn't like it. Where is she supposed to find a toilet when she's on the street? So drag it on, say, she'll take the medicine on holidays , but then there is something else to do and diuretics are forgotten. This is a question for family doctors - why don't they get patients to use these drugs and understand why they need them?"

A chain reaction is formed - heart failure causes edema, we do not use diuretics, venous edema is added. If we sit a lot, gravity edema also takes effect. All this leads to the fact that the skin is not properly supplied with blood and nutrients, so its structure changes. Ada breaks and starts to ooze. "Patients tell me - doctor, I don't understand why the skin on my legs starts to leak! I'm sitting, and there's a puddle at the bottom," says Aleksandra Kušpelo and explains that lymph flows through the micro-cracks of the skin and interstitial fluid accumulates in the legs. There are microbes on the skin, they like this moist and warm environment, so they activate and infect the wound. Disorders of skin trophism (a set of cellular metabolic processes) begin - this results in a difficult-to-treat wound called a trophic ulcer.

It is important to see a specialist

As soon as an ulcer has formed, it is very important to consult a specialist without delay. Doctor Alexandra Kušpelo's experience shows that many people visit family doctors and surgeons who do not specialize in the treatment of ulcers. Various remedies are then tried, but without success, and the ulcer is admitted.

The specialist first finds out the origin of the ulcer - whether it is venous or arterial insufficiency or something else. Treatment depends on it. 80% of trophic ulcers are of vascular origin, that is, they arise due to blood circulation disorders. However, they can have a different etiology - there are also oncological, post-traumatic, dermatological and other types of ulcers.

In order to find out the causes of the formation of an ulcer, the doctor asks the patient about other diseases, and also uses tools. "The number one tool is the hands - you have to feel the patient's pulse. This should be done by family doctors as well, but unfortunately, many do not have time not only to feel the patient, but even to make them undress in order to examine it." Aleksandra Kušpelo believes: if this happens, the patient should insist that he wants to be properly treated and ask for a referral to a specialist.

With ties and socks

Most ulcers are of venous origin. Then the treatment of venous hypertension should be started. Compression therapy with bandages or special compression stockings is performed in parallel with ulcer care. Many patients consider them a burden, because they press, are uncomfortable, difficult to put on by yourself, in addition, they must be specially washed and changed after a certain period of time because they stretch and no longer provide the pressing effect. For others, socks or ties do not hold, because the legs are thick at the top, but thinner at the ankles, many find them especially painful in the summer.

"It takes time to convince patients of the necessity of socks and to get them used to wearing them. Not all patients can put them on themselves. If a person is 80 years old, has a deformity of the hip joints or spine, or is overweight and has difficulty bending over, even shoes are difficult to put on, not to mention compression stockings. But there are devices that make it easier. Others are helped by relatives," the doctor sees a way out.

If the ulcers are large, at first it is suggested to use special bandages instead of socks, but the dressing should be done 2-3 times a week. Going to the doctor every time is difficult. "A patient from Purvciem can come to me 2-3 times a week, but hardly from Kuldīga. Then it is important to have helpful relatives around.

We try to train them how to properly tie compression ties and how to put on compression socks. It's not easy! If the patient is a ballet dancer, maybe you can do it yourself, because the sock should be pulled on with a stretch, keeping it parallel to the leg. Otherwise, you can't do without help."

It is treated orally and externally

Venous ulcers are more often formed on the inner ankle. If nothing is done and untreated, circular ulcers can develop. "I've had patients come to me with no skin on their legs from the ankles to the knees - just one big wound."

Ulcers hurt, so many try remedies on their own hands so that there is no pain. "It must be understood - venous ulcers hurt because they are infected, venous hypertension has not been eliminated, compression therapy is not used and the skin is stretched. Treatment must be started - like unraveling a huge knot one thread at a time," says Aleksandra Kušpelo.
If there are signs of inflammation, culture is done to find out which microbes to fight against. If the microbes multiply faster than the human immune system can resist, antibiotics should also be used. A modern device is available for cleaning wounds - an ultrasound-assisted ulcer debridement device. "No, it doesn't hurt," promises the doctor. "With it, you don't even touch the ulcer! Ultrasound flows from a special tip and, at the same time, the physiological solution as a very fine mist. It is possible to remove the top layer of the wound, which contains microbes."

Staphylococcus aureus resides most often in wounds, but often there is a combination of 3-5 bacteria, which is also joined by fungi. "They all unite against us, forming a biofilm. It should be removed, but it is not possible with tweezers or scissors. Therefore, the wound should be rinsed, disinfected, treated with an ultrasound device."
When the ulcer is cleaned and the swelling is reduced, the discharge and pain decrease, the patient's well-being improves. Bandaging is no longer necessary so often, 1-2 times a week is enough. Techniques can be started to promote healing. One of the latest - injections of enriched plasma directly into the wound. The plasma preparation is prepared from the patient's own blood. The procedure is not complicated and has good results, because the preparation stimulates the formation of new tissue.

The mystical salve and resistant bacteria

How long is it possible to recover? Doctor Aleksandra Kušpelo answers: "Theoretically, the trophic ulcer should heal within three months, but this is only possible under ideal conditions - if everything goes according to plan, if the patient has helpful relatives, if there is no shortage of funds, because not all treatment is paid for by the state. For example, not cleaning with neither an ultrasound machine nor the enriched plasma injections are available on the budget. You also have to buy socks and bandages yourself. That is a very big problem, because the state only pays for the consultation and dressing for now. The rest can only be offered, and then the person has to calculate what he can afford I can say one thing - all the best-known manufacturers of local care products are represented by us."

One of the most common mistakes made when trying to treat ulcers on their own is that many people think that it can be done by using some mystical ointment. "Ointments are not in fashion in the treatment of ulcers," says the doctor and explains - the discharge from the wound is watery, but the ointments are oily. Every student knows that fat and water are incompatible. An emulsion forms that covers the wound, oxygen does not reach it, and the wound does not heal. The secretions together with the emulsion irritate the edges of the wound. Hydrogels - water-based agents - are widely used in the care of such wounds. Their types are different, they must be chosen individually, according to each patient and the stage of the wound.
"It would be normal if the stage of black necrosis was followed by yellow necrosis, then - granulation and finally - epithelization, the formation of new skin. However, if one of the stages of treatment is stopped, there may be a regression."

A major problem in wound care is bacteria, which cannot be defeated by antibiotics. In the past, we talked mostly only about the resistant flora that had developed in hospitals, whereas now we are increasingly encountering resistance acquired at home. These are the consequences of improper antibacterial therapy," considers Aleksandra Kušpelo. "Often doctors, not knowing the stage of the infection and what caused it, prescribe broad-spectrum antibiotics for safety's sake. Later, it turns out that the patient has used a bit of the drug, the microbes have spat on it, but the immune system has reacted, so this drug will no longer be able to help. Therefore, it is very important in case of any infection - be it sinusitis or trophic ulcer - to specify what caused it and which antibiotics will be effective."

Walk - both for the healthy and the sick!

After the healing of a trophic ulcer, not only a scar remains, but also pigmented skin - brown and hard, but very fragile. You must continue to wear compression stockings - mandatory, from morning to evening. In parallel with the treatment and also later, you should consult a vein doctor phlebologist.

"You definitely need to know how phlebologists can help further, because every third ulcer has a relapse. It comes back," says the doctor with regret. "Others do not heal for half a year, a year or two, it is very difficult to treat them. Unfortunately, there are also incurable ones - those that can only be cared for and maintained so as not to become the cause of death."
Women have a higher risk of trophic ulcers, especially if there is a genetic predisposition - if the mother or grandmother already had varicose veins. Other risk factors - standing or sitting work, venous return disorders during pregnancy.

The best prevention of trophic ulcers? You should do sports, walk a lot, generally follow a healthy lifestyle. Walking is an important part of therapy if the ulcers have already formed, emphasizes the doctor. "When walking or running, the calf muscle compresses the arteries and veins, blood flows both up and down. That's why you should walk 3-5 kilometers a day. You should tie your legs and wear compression socks."

If the legs are swollen, lymphatic drainage, or so-called inflatable pants, can help - they are used if there is severe lymphostasis. If you have a long journey ahead on a bus or plane, it is recommended to wear compression socks. A good thing for prevention is massaging from the toes up, as well as leg exercises simulating pedaling.

GOOD TO KNOW
Putting on compression stockings is not easy,
but get used to them and wear them on a daily basis
is a real test.

GOOD TO KNOW
Doctor's consultation and bandaging of trophic ulcers are available to patients for state money. Compression stockings or bandages as well
the latest therapeutic methods can only be achieved at one's own expense.

Zane Eniņa, in magazine 36.6 C Healthier More Harmonious Smarter