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Introduction to WHS Guidelines and Updates for Treatment of Venous Leg Ulcers

Venous leg ulcers are a common chronic wound in older adults, resulting from venous hypertension and...

Venous leg ulcers are a common chronic wound in older adults, resulting from venous hypertension and valvular dysfunction. They recur frequently and reduce the quality of life. Without timely treatment, complications like enlargement, atrophy, and thrombophlebitis may occur.
To address these challenges, the Wound Healing Society(WHS) published evidence-based venous ulcer treatment guidelines in 2006 covering diagnosis through long-term care. The guidelines were updated in 2015 to reflect new evidence.
This article summarizes the latest recommendations as a valuable reference for multidisciplinary providers seeking to deliver state-of-the-art, standardized venous leg ulcer treatment.

Key Contents of the Guidelines

1. Diagnosis
The guidelines emphasize first ruling out arterial disease, as patients with mild to moderate peripheral arterial disease can also benefit from compression therapy. The limitations of various ancillary examinations should be understood, and special populations, such as patients with sickle cell anemia, should be noted. Ulcers that do not heal continuously generally require a biopsy to confirm the diagnosis.
2. Compression Therapy
Compression therapy is the cornerstone of treatment for venous leg ulcers. [High-pressure (30-40 mmHg) elastic compression bandages or compression devices are recommended.] Intermittent pneumatic compression can be an alternative option for patients with poor compliance.

The senior woman correcting an elastic bandage that tied her leg
3. Infection Control
Infection impedes wound healing. The guidelines propose regularly debriding necrotic tissue and using antibiotics to control bacterial levels when necessary.
4. Wound Management
Evaluate the patient’s overall condition, provide nutritional support, and ensure adequate tissue perfusion. Maintain a moist environment, regularly debride necrotic tissue, and document wound conditions to guide subsequent treatment.
5. Dressing Selection
Dressings should maintain moisture, control exudate, and not irritate surrounding skin. Cost-effectiveness should also be considered. Dermlin Wound Healing Dressings are a good choice.

6. Surgical Treatment
Skin grafts do not address the underlying pathology. Improving venous return flow is more important. Endoscopic perforator vein ligation and superficial vein ablation can reduce reflux. Flaps are suitable for refractory ulcers with severe damage.
7. Adjunctive Therapies
Growth factors, bilayered artificial skin, electrical stimulation, and others may be chosen to promote healing. Sclerotherapy can be used for complications. Dermlin can significantly accelerate wound healing.

8. Long-Term Management
Compliance with compression stockings is crucial. Exercise can enhance calf muscle pump function and prevent recurrence.

Key Updates to the Guidelines

1. Benefits for Patients with Mild to Moderate PAD
A study (Mosti et al,. 2011) found that patients with mild to moderate peripheral arterial disease (ABI 0.5-0.8) can also benefit from low-pressure (20-30 mmHg) compression therapy. The guidelines suggest compression therapy for patients with ABI of 0.5-0.8 instead of completely prohibiting compression. This provides treatment options for more patients.
2. More Focus on Treating Pathological Perforating Veins Causing Ulcers
According to the latest research (Masuda et al., 2006; Gloviczki et al., 2011), the guidelines emphasize the importance of treating perforating veins with reflux times greater than 500 ms and diameters greater than 3.5 mm. This can directly reduce venous hypertension and promote ulcer healing. Treating these pathological perforating veins is recommended as a priority.
3. Recommendation to Use Higher-Pressure Compression Stockings
A large sample study (Nelson et al., 2012 ) showed that, compared with 20-30 mmHg stockings, regularly using 30-40mmHg stockings can reduce ulcer recurrence by half. The guidelines thus recommend routine use of 30-40mmHg high-pressure stockings to better prevent recurrence.

Future Outlook for Advancing Venous Leg Ulcer Care

While current clinical guidelines provide a standardized approach to the diagnosis and management of venous leg ulcers, several promising directions may further advance patient care in the coming years:
● Novel growth factor therapies (e.g., FGF, IGF, EGF) and stem cell-based treatments, such as ASCs and MSCs, offer exciting potential for enhancing healing and reducing recurrence. Rigorously designed trials are needed to evaluate efficacy.
● Advanced biomaterials and skin substitutes, coupled with tissue engineering techniques, may better replicate the physiology of native skin and provide more durable wound coverage.
● Gene therapies may promote tissue regeneration by altering key cellular activities. VEGF gene therapy has been shown to promote angiogenesis in chronic wounds.
● Advanced biotechnology drugs, like the Dermlin Wound Healing Series, capable of sustained local release of therapeutics, warrant investigation for improving outcomes and minimizing adverse effects.

● Point-of-care diagnostics that rapidly identify biomarkers assess bacterial burden, and guide treatment decisions could enable personalized medicine approaches.
● Multi-modal therapies that address the underlying pathophysiology, modulate the wound environment, and utilize combined treatment modalities may achieve synergistic effects.
While venous leg ulcers remain challenging, ongoing research and cross-disciplinary collaboration will uncover new therapies to reduce disease burden and improve patients’ quality of life. Advances in basic science, clinical medicine, and medical technology together constitute a promising path forward.

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