Dermatology Chair Co-Authors Guidelines for Treating Lower-Extremity Ulcers

A University of Miami Miller School of Medicine dermatologist offers guidance to physicians diagnosing and treating leg and foot ulcers in a collaborative article published October 19 in the New England Journal of Medicine.

Robert S. Kirsner, M.D., Ph.D., examines a patient’s leg ulcer.

“Chronic lower-extremity wounds affect millions worldwide, and optimizing results through evidenced-based care can improve patient outcomes, restore healthy limbs and save lives,” said Robert S. Kirsner, M.D., Ph.D., Chairman and Harvey Blank Professor in the Department of Dermatology and Cutaneous Surgery, professor of public health sciences, and director of the University of Miami Hospital Wound Center. UM is among the leading academic medical centers in clinical care and research related to wound healing, tissue repair and regeneration.

Kirsner is the senior author of the article, “Evaluation and Management of Lower-Extremity Ulcers.” Co-authors were Adam J. Singer, M.D., and Apostolos Tassiopoulos, M.D., at Stony Brook University.

“Even with the best care currently available, 25 to 50 percent of leg ulcers and more than 30 percent of foot ulcers are not fully healed after six months of treatment,” Kirsner said. “Measuring improvement, use of evidenced-based supportive therapies and appropriate referrals give patients the best chance to rapidly health their wounds.”

In the article, Kirsner and his co-authors discuss several types of lower extremity ulcers, including:

• Venous ulcers caused by damage to the valves in leg veins or dilation of the veins. Patients with this condition often report aching or burning pain (or both) and swelling in the leg that increases during the day and lessens with leg elevation.

• Arterial ulcers that result from impaired tissue perfusion. This condition is more common among smokers and individuals with diabetes mellitus, hyperlipidemia, and hypertension. Patients may report intermittent pain while at rest that worsens when the leg is elevated.

• Diabetic foot ulcers caused by poor blood supply or neuropathy (lack of sensation). They are usually located at sites of trauma or prolonged pressure, such as the tip of the toe or the bottom of the foot.

• Pressure ulcers that occur over the heel or other bones in immobile patients who cannot readily adjust their position.

“Most ulcer types can be identified on the basis of their appearance and location, and confirmed by ancillary testing,” Kirsner said. “However, medical professionals should pay close attention to coexisting medical conditions, such as diabetes mellitus or peripheral arterial disease, which may need to be addressed along with the wound itself. It is also vital to look for signs of infection, so that an appropriate antibiotic treatment can be started as quickly as possible.”

Patients with any limb-threatening or life-threatening conditions should be admitted to the hospital, and a vascular surgeon or wound specialist should be consulted immediately, said Kirsner in the article. Patients with systemic infection or a local infection that does not respond to oral antibiotics should be admitted for intravenous antibiotics. Other patients may require home health care, admission to a skilled nursing facility or treatment by a primary care physician or wound specialist, should healing fail to occur in a timely fashion.

“Whenever possible, we have based our recommendations on findings from randomized trials,” Kirsner said. “While there may be disagreement regarding some recommended approaches, the guidelines we suggest have been shown to be useful in our practices.”

Tags: dermatology, leg and foot ulcers, Miller School of Medicine, Robert S. Kirsner, The New England Journal of Medicine, University of Miami