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362 CliniCalManageMentofthelowerliMb
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mobility to name just a few, require a shared approach to management and are discussed elsewhere in this book, as are the wider
determinants of health. Medication management is part of the wider
approach to assessment of the person and is discussed here.
Medication Management
Gathering information about the patient’s previous medical and surgical history is an important part of the holistic assessment described
in Chapters4 and5. It includes asking the patient what medications
they are currently prescribed, even for conditions that may not, it
would appear, be related to the lower limb problems they are experiencing, and so understanding the medications that are important in
lower limb management is an essential component of eective practice. The medications that it is important to know about have been
categorised into three areas: medications that may cause foot and leg
ulceration, medications to treat ulceration and medications that can
cause or exacerbate swelling in the ankle and lower limb (also known
as ankle oedema).
Medications That May Cause Leg andFoot Ulceration
Several medications are related to the development of lower limb
ulceration. Often this is linked to delayed healing caused by medicines such as corticosteroids, nonimmunosuppressants (NICE2023). Broadly speaking these medications are linked to delayed wound healing and increased susceptibility to infection, which contribute to the overall pathophysiology of a
hard- to- heal ulcer. However, two medications are identied as
directly causing leg and foot ulceration, and therefore it is important
that clinicians working within leg ulcer practice have an awareness of them.
Nicorandil
Nicorandil, a vasodilatory oral medication (tablet form) that is widely
used in the treatment of stable angina (BNF2023a), has been identied as a cause of ulceration (NICE2023). Nicorandil works by relaxing and widening circulatory blood vessels; this in turn increases the
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steroidal anti- inammatories and
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supply of blood and oxygen to the heart, which serves to reduce the
chest pain that angina causes. Frequently nicorandil is linked to
mucosal ulceration, and typically these ulcerations are observed in
mucosal areas, such as the peri-
anal region, nose, eyes and the oral
cavity, with skin ulceration being seen less often (BNF2023a). However, when skin ulcerations are present, 60% of occurrences are
observed on the leg (Babic etal.2018).
The ulcers are often described by patients as painful. On assessment they are frequently localised in nature and may extend into the
deeper tissues. There is also usually little evidence of granulation
activity in the dermal bed (Patel and Harding2010). A direct link
between dose and occurrence of skin ulceration is apparent and so
clinicians should be mindful not just of those patients who have
recently commenced taking nicorandil, but also those who have had
a recent dose increase (Patel and Harding2010). The treatment of a
nicorandil- induced ulcer is to cease taking nicorandil; however, this
course of action is a multidisciplinary decision that should be made
in partnership with the patient. An alternative medication to manage
the angina should be prescribed. A full medication review should be
led by an appropriately qualied and experienced prescriber.
Hydroxycarbamide
Hydroxycarbamide is a cytotoxic oral medication (tablet form) that is
used mainly in the treatment of cancers; it is also used in the treatment of psoriasis and sickle cell disease (BNF2023b). Hydroxycarbamide (formerly known as hydroxyurea) has been identied as a cause
of lower limb ulceration (NICE2023). It is recognised as having other
dermatological side eects beyond leg ulceration, such as dry skin,
scaling of skin, erythema and hyperpigmentation. Hydroxycarbamide interferes with cell growth, which is a welcome eect within
cancer management, but this process also damages basal keratinocytes and can interrupt the growth of collagen too, which causes dermatological side eects and can occasionally result in complications
such as hydroxycarbamide- induced ulceration. This is because
hydroxycarbamide can cause red blood cells to become deformed and
enlarged in size, which can impair the ow of oxygenated blood into
the microcirculation, which leads to ulceration, particularly where
there is co- existing trauma to the limb (Swain2014).
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Ulcers caused by hydroxycarbamide are frequently described as
painful, and clinical assessment will often identify brotic ulceration, with trophic, perimide ulcerations it is reported that necrosis may be present
(Swain2014). The most common sites for this type of ulceration are
at the tibial crest or retro malleolar area. However, ulcers are not limited just to this area and can also appear on the plantar or dorsum
aspects of the foot.
Similarly to nicorandil, the treatment for this form of ulceration
is to cease administration of the medication, but it is imperative that
this is done under the direction of the MDT. It is also worthy of note
that even after the ulcer has healed, recommencing hydroxycarbamide will lead to reoccurrence of the ulceration in most cases.
It is important in leg ulcer management to note that if an ulcer is
not healing as you would expect it to, despite the optimum treatment
being employed, question why. Have you achieved a correct diagnosis for the cause of the ulceration? Do you need to revisit the principles of holistic assessment, including previous medical history,
unusual presentation and currently prescribed medications?
Medications Used toTreat Venous Ulceration
ulcerative skin. In up to 25% of hydroxycarba-
Pentoxifylline is an oral medication (tablet form) that may be prescribed to aid in the healing of venous leg ulceration in some patients
(BNF2023c). It has multiple eects on the circulatory system, such
as causing a decrease in blood viscosity and decreased platelet aggregation and adhesion, which assists in improving blood ow and
peripheral tissue oxygenation (Hassan etal.2014). It also has antiinammatory eects, since pentoxifylline can inhibit the production
of inammatory cytokines. These actions make it a useful treatment
in venous leg ulceration (Annamaraju and Baradhi2022).
However, pentoxifylline has several contraindications and cautions that make it unsuitable for many of the patients seen within
daily lower limb practice. These contraindications and cautions
include people with cardiac arrhythmias, hypotension, coronary
artery disease, diabetes and severe hepatic and/or renal impairment
(NICE2023; BNF2023c). Pentoxifylline also interacts with many of
the commonly prescribed medications in patients who present with
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leg ulceration, for example antihypertensives, antidiabetics and warfarin (Annamaraju and Baradhi2022). Older patients are at particularly high risk of the side eects from pentoxifylline, as they frequently
have co-
morbidities and polypharmacy, which can put them at higher
risk of hypotension, falls and hypoglycaemia (Annamaraju and Baradhi2022). What this means for clinical practice is that while NICE
(2023) recommends that pentoxifylline can be a useful adjunct therapy in the management of venous leg ulceration, in practice it is seen
less widely used outside of specialist MDTs.
Non- venous Ulceration– Managing Medications
Ulcers that present due to other aetiologies, for example pyoderma
gangrenosum, sickle cell ulceration and ulceration secondary to
other conditions, such as rheumatoid arthritis, require medication
management as the primary intervention to manage symptoms and
promote healing. These less common causes of ulceration are discussed in Chapter3.
Medications That Can Cause or Exacerbate Swelling inthe Ankle
andLower Limb
Swelling and treatment of swelling are vital components in the overall comprehensive management of the lower limb. Further information on chronic oedema and lymphoedema can be found in Chapters1
and2. However, within the context of medication management, it is
important to examine medications that can cause or exacerbate
swelling in the ankle and lower limb. See Table8.3 for a list of medication categories that should be considered when swelling is present.
This is most commonly observed in calcium channel blockers, for
example amlodipine and nifedipine. Calcium channel blockers are
usually prescribed to treat conditions of the heart and blood vessels,
for example angina, hypertension, certain heart arrhythmias and less
frequently Raynaud’s phenomenon (a long- term condition that
causes painful and cold ngers and toes due to narrowing of the
arteries that provide blood supply in the hands and feet). Calcium
channel blocker–induced ankle and lower limb oedema appears to be
due to redistribution of uid from capillaries to interstitial spaces.
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TABLE8.3
andlower limb (ankle oedema).
Medication Examples
Calcium channel blockers (calcium
channel antagonists)
Sex hormones Hormone replacement therapy
Corticosteroids Prednisolone
Antipsychotics Risperidone
Antidiabetics Pioglitazone
Proton pump inhibitors Esomeprazole
Source: Adapted from Keeley (2018) and Specialist Pharmacy Service (2020).
Medications that can cause or exacerbate swelling inthe ankle
Amlodipine
This occurs despite the diuretic nature of some calcium channel
blockers (Keeley2018).
It is also worthy of note that certain diuretic medications that are
used to treat oedema in heart failure are not indicated in chronic
oedema and lymphoedema, as they are clinically ineective in this
type of swelling. In cases of chronic oedema and lymphoedema, prescribing loop diuretics may exacerbate the swelling through causing
an increase in the oncotic pressure of the oedema uid. This is due to
an increase in interstitial protein concentration because of reduced
water entry through capillary ltration. This, in turn, can exacerbate
the formation of brosis (hardening) of the oedema in the long term.
Inappropriate use of diuretics can also put patients at risk of dehydration in the short term (Keeley2018).
Step2: TheLimb
A thorough assessment of the limb is necessary and gait, mobility,
biomechanics and the potentially adversarial relationships between
them (Farrelly2018) are explored in Chapter4, along with more
information about how to assess the limb specically in Chapter5.
This chapter will discuss eective skin care and exudate management, which are essential to overall good limb health, along with
eective compression therapy to promote ulcer healing.
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The Importance ofGood Skincare When Undergoing Compression Therapy
The skin has many important functions. It provides a protective
defence against mechanical, thermal or chemical trauma, and
functions as an immunological barrier against penetration of the
body by micro-
organisms. It provides thermostasis, regulating the
blood supply to the skin and controlling heat loss due to sweat production. The skin also has a metabolic function in the production
of vitamin D (LeBlanc et al.2018). The skin is a sensory organ:
somatic nerve endings provide the body and brain with important
information about the external environment and potential hazards
such as heat. The skin is a social communicator of colour, temperature, pheromone secretion and texture. Compromises of skin
integrity in any part of the body can impair these important functions (LeBlanc etal.2018) and therefore ulceration could be framed
as organ failure, given that the skin is the largest organ of the
human body.
Before we consider the application of compression therapy, the
rst step is to ensure that the person receives good skincare, which is
a key component of lower limb management. Robust hygiene and
application of a suitable emollient to moisturise the skin will improve
the overall condition of the skin, reduce the risk of skin tears and
minimise itching and excoriation to the skin, which is frequently a
clinical symptom of lower limb ill-
health (Ritchie 2018). Omitting
basic skincare requirements from lower limb management can aect
a person’s ability to tolerate compression therapy. Therefore, cleansing and moisturising the limb are fundamental aspects of treatment
(Hopkins2005) that should not be overlooked (Ritchie2018). Skin
washing and moisturising also present an important opportunity to
inspect the skin for signs of trauma or damage alongside monitoring
for opportunistic infections such as tinea. Table8.4 explains the three
key steps to good skincare.
Once these three key steps have been followed, it is possible to
think about the next step in clinical management, the management of exudate if it is present. A more detailed exploration of
emollient use in conjunction with compression hosiery stockings
and in maintenance/prevention of reoccurrence is oered in
Chapter9.
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TABLE8.4 The three key steps togood skincare.
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Step1 Cleansing Step2 Drying Step3Moisturising
The skin requires careful
washing to ensure hygiene
without compromising skin
integrity.
A full foot and leg wash should
be done three times per week
as a minimum, or at each
bandage change if the person
is receiving compression
bandaging for their lower
limb treatment. This will
remove the build- up of
emollients, dirt and microorganisms from the skin,
which can be uncomfortable,
pose a risk of infection
(Todd2014) and may aect
the person’s ability to tolerate
compression therapy.
The skin should be washed with
warm, not hot, water. A
perfumed soap substitute
nonshould be used to minimise
the risk of triggering skin
sensitivities. Normal soap can
cause the skin to become
overly dry and disrupt its
protective acid mantle
(Voegeli2008).
Special care is needed to wash
deep folds of skin on the
lymphoedematous limb. It is
important to ensure that the
folds are cleaned of matter
that may provoke an
infection.
The skin can be cleansed
eectively using tap water, in
a bowl lined with plastic,
using a clean annel (Wound
Care People2019). If use of a
bowl is not possible,
consideration may be given to
the use of a disposable wipe
and tap water.
The skin should
be patted dry
carefully after
washing,
without
rubbing, to
avoid
damaging or
tearing
fragile skin.
After washing, it
is important
to dry in
between toes
and skin folds
thoroughly to
ensure no
moisture
remains that
might cause
maceration or
moistureassociated
skin damage
(Todd2014).
Finally, moisturising
with the correct
emollient therapy
is necessary.
Emollients will
maintain the
protective barrier
of the skin by
‘trapping in’
moisture
(Penzer2012).
Remember to check
for allergies prior
to application.
Emollients should be
applied in the
direction of hair
growth to avoid
folliculitis
(Ritchie2018).
Emollient creams are
preferred for those
using compression
hosiery as
ointments degrade
the stockings. It is
important to leave
the emollient to
dry before putting
on the
hosiery (Wounds
UK2021).
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Exudate Management
Exudate is the uid that is produced from a wound, lesion, abrasion
or area of inammation as part of the normal healing process (Lloyd
Jones2014). The composition of exudate is complex: it can contain
several components such as proteins, nutrients, electrolytes, matrix
metalloproteinases, growth factors, inammatory mediators, neutrophils, platelets, macrophages and cellular waste products, to name
just a few (WUWHS2019). However, wound healing is adversely
aected when exudate is overproduced, the composition of the exudate is incorrect or the exudate is leaking beyond the dermal bed onto
the peri-
wound skin (Moore and Strapp2015). A thorough assessment of exudate will inform the treatment plan; see Chapter 5 for
more information about exudate assessment.
Achieving moisture balance within the wound bed will support
healing by providing a moist environment that supports cell migration, nutrition for cell metabolism and cell proliferation. Wounds
also require a moist environment to assist with autolysis and removal
of non- viable tissue present in the wound bed, but similarly to an
overly moist wound bed, an overly dry one can be just as detrimental
to wound healing and in particular will inhibit the migration of epithelial cells (Tan and Dosan2019). Too much exudate can have a
destructive eect on the wound bed and the healthy peri- wound
skin, causing maceration and skin breakdown, which will increase
the size of the wound, cause pain, increase the risk of infection and
require more frequent dressing changes. Therefore, achieving moisture balance is key to the management of exudate to promote the
optimum healing environment (Nuutila and Erikson2021).
Exudate presents in a variety of dierent forms. Examples
include a watery liquid, which can be odourless and opaque/clear in
colour; it can also be thicker in terms of consistency, which is
described as purulent; or with the presence of red blood cells it can be
described as haemo-
purulent or haemorrhagic (WUWHS2019). This
list is not exhaustive and more detailed information on the types of
exudate can be found in Chapter5.
A change in the appearance and/or the consistency of exudate
can provide important information regarding progress or lack of it
towards healing, for example an increase in the presence of protein
in the wound due to long- term inammation or the occurrence of
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infection can cause the exudate to change and become sticky and
thickened in consistency. In contrast to this presentation, exudate
that is clear and runny has a lower protein content and may be associated with lymphovenous disease or heart failure (Adderley2008).
This information is pertinent in the management of lower limb
wounds, where the presence of oedema and swelling must be managed or healing will be signicantly compromised. Signicant
resources are used in the pursuit of exudate management such as
super-
absorbent pads and nursing time. Optimising compression
therapy will manage the oedema and reduce exudate.
Odorous exudate can be attributed to soiled dressings on
removal (WUWHS 2019) and some dressing types, for example
hydrocolloid dressings, are particularly associated with malodour
(WUWHS 2019); however, this type of dressing is used less frequently in the management of lower limb ulceration. Odour is also
frequently attributed to the presence of micro- organisms in the
wound and poorly managed exudate. Management of microorganisms through debridement and/or antimicrobial therapy is
discussed later in this chapter.
The volume of exudate produced is dependent on several key
factors, including wound type, wound location and the presence of
micro- organisms within an acute infection, or it can be linked to a
wound becoming stuck in the inammatory phase due to biolm
presence. A lower limb ulceration can produce a greater volume of
exudate due to lower limb dependency, which can increase pressure
on the circulatory and lymphatic systems causing leakage of uid
into the interstitial spaces (Health Service Executive (Ireland)2022).
The correctly calculated dose of compression therapy is fundamental for eective exudate management for the lower limb, as
reversing the pressure on the venous and lymphatic systems of the
lower limb will address the source of the exudate (Wounds International2015). The importance of the lymphatics in managing swelling and oedema of the peri- wound skin and limb has changed focus
in recent years. It was previously thought that reabsorption of the
uid was via the capillary networks back into the circulatory
system (Starling 1896). However, more recent research by Mortimer and Rockson (2014) refutes this and indicates that the lymphatic system is the key system in reabsorption of the uid (see
Chapter2). This reinforces the need to view issues with regard to
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exudate in particular and the lower limb in general as lymphovenous in nature.
Exudate is not controlled by absorbent dressings, but these provide a way of absorbing and managing the excessive exudate to protect the wound and peri-
wound skin, while the compression works to
reverse the venous hypertension and presence of uid in the interstitial spaces of the lower limb. Several dressing options are available to
absorb exudate of the lower limb, including gel forming dressings
and super- absorbent pads, also known as super- absorbent polymers,
all of which are designed to wick away excess moisture from the skin.
See Table 8.5 for the threefold approach to dressings for managing exudate.
It is important when applying super- absorbent pads to acknowledge and act on the eect that this will have on the limb circumference, thus reducing the dose of compression therapy. This is
rationalised by Laplace’s law, discussed later in this chapter.
TABLE8.5
Stage Approach Reason
Compression
therapy
The threefold approach toexudate management.
The correct individual dose of
compression therapy must
be applied following holistic
assessment of the patient.
Early intervention employing
mild compression therapy
(of up to 20 mmHg)
(NWCSP2023) can be
applied immediately in the
absence of red ags or
contraindications. This
intervention should be
maintained until a full
vascular assessment is
carried out. Early
intervention techniques are
discussed in Chapter9.
To address
venous
hypertension
and to ensure
uid is
absorbed into
the lymphatic
system and
transported
back into the
central
circulatory
system.
(Continued)
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