Chronic wounds appearing on the lower extremities can be the result of numerous pathophysiological processes.
According to the primary cause we differentiate between
1/ venous circulation disorder
2/ arterial circulation disorder
3/ diabetes related foot wounds
The different wound types have different forms of appearance, which bear special significance in terms of the applicable therapy.
Ulcers appearing as a result of venous circulation disorder are what is commonly called as leg and foot ulcer (ulcus cruris). The most common reason of its appearance is neglected primary varicosity and only to a lesser extent the post-thrombotic conditions.
Damage to arterial circulation may be accompanied by gangrene on the lower extremities at the tip of the toes.
Its types are the following:
wet gangrene – which, without proper treatment, is a progressing process, the negligence of which may lead to sepsis.
dry gangrene – which means the necrosis of some tissues and is irreversible in the particular body area. However, in these cases the body can separate the intact tissue from the necrotic tissue, consequently, these processes pose no life-threatening situations.
Patients with diabetes often experience the appearance of corns and callosities on foot areas exposed to pressure, under which wounds and ulcers may formulate. In 85% of the cases the reason behind these phenomena is neuropathic damage, the occurrence of serious primary arterial circulation disorders is far less frequent.
When discussing chronic wounds, it is important to mention bedsore or decubitus, which often arises as a result of maltreatment. However, there are several underlying diseases e.g. paralysis or tumorous diseases, in which cases it may occur even if the patient has been given the most careful treatment.
At this point the possibility of skin tumours appearing in the form of chronic wounds must also be touched upon as their exploration requires histologic study.
In each case the accurate identification of the underlying disease(s) is indispensable for the successful healing of the wound in compliance with the principles of modern moist wound treatment.
In case of venous circulation disorders, which may easily be considered a public disease, the vascular system expands and as a result of the inadequate functioning of the vein valve system blood regurgitation slows down, the foot becomes swollen and oedematous, and after a while the skin may even become discoloured. Depending on the individual’s sensitivity, this condition may entail pain, a sensation of heavy feet or night cramps but does not necessarily cause considerable physical pain.
The basis of the treatment of already existing ulcers is the proper recovery of the functioning venous system. If this does not take place, the blood continuously circulating in the expanding veins can serve its transporting function only with increasing difficulties, as a result of which the tissues on the foot become far more vulnerable due to the inadequate circulation, which leads to the appearance of hard-to-heal wounds even after minor traumas.
Ways of healing venous circulation:
Previously applied surgeries entailed enormous traumas and are therefore being replaced by so-called “intravascular” surgical actions, during which the closure of the pathological enlargements can be achieved with the least possible traumatization using laser or radiofrequency energy.
If the appearance of the wound on the foot cannot be prevented, every measure must be taken to heal the ulcer.
Patients primarily visit their doctor only when the wound surface is already necrotic as a result of the necrosis of the tissues. If, in addition to that, the wound has been superinfected, the inflammation process makes the patient’s life even more difficult.
In this condition it is essential to remove the necrotic tissues as thoroughly and quickly as possible without damaging the living tissues. There are many well-known ways to do this, e.g. the simple mechanic wiping off of the wound surface or the application of the most cutting edge ultrasonic device, just to name a few.
Under no circumstances may the cleaning of the wound base be carried out with the use of chemical or lytic agents!
The wound and the perilesional area can be cleaned with the use of physiological saline solution, for disinfection there are several pharmacological preparations at our disposal, all of which are non-prescription products.
It is important to alternate among the various preparations after a while in order to prevent the development of resistance.
The next stage of wound healing is the granulation of the wound.
In this stage we have to ensure a moist environment in order to facilitate the strengthening of the granulation tissue. Do not apply erosive disinfectants damaging the cells on the newly formed granulation tissue! The application of pastes or ointments is not recommended either.
In this healing stage hydrogen-based preparations can be very useful, gels containing zinc-hyaluronate are particularly recommended.
Hyaluronate is a natural constituent of the skin and has excellent moisturizing characteristics. The skin of diabetic patients contains scarcely any of it regardless of their age! Ensuring its supplementary supply is highly recommended with all types of wounds in order to facilitate healthy wound healing.
Zinc is necessary in the stage of granulation and epithelisation as well as for the proper functioning of the immune system. In addition, due to its antiseptic quality it prevents the superinfection of wounds. The antibacterial effect of zinc is stronger than that of silver but without the danger of accumulation.
With pocket wounds it requires extra care and attention to make sure that the granulation process should start from the wound base. It is extremely dangerous if retention cysts remain under the contracting wound edges as the inflammation spreading into the deep tissues may cause a lot more dangerous complications.
It is important to take into consideration the fact that in the various stages of wound healing the quantity and quality of wound secretion may vary significantly, therefore always use dressing materials suitable for the current condition of the wound.
It is also important that dressing materials financed by OEP are to be changed in 2-month turns if wound treatment has been successful up until then.
It cannot be overemphasized how crucial it is to apply adequate compression therapy and, if necessary, pressure-relieving methods in the entire course of the healing process.
However, the healing of the wound does not mean the end of the process since the maturation of the scar tissue takes months to finalize. Therefore, the local application of the zinc-hyaluronate gel as well as the compression dressing has to be maintained until the wound surface has regained its proper and final resistance characteristics. This way we can heal the ulcer and prevent its recidivation.
Summary: The toolkit at our disposal provides us an opportunity to heal the wound completely and without recidivation!
Whereas the existence of the ulcer means the state of social exclusion for the patient, healing the wound makes it possible for them to remain active in the labour market and reintegrate into society!