**7. Discussion**

Venous leg ulcers occur as a complication of CVI. With the aging of the world's population, an increase in the number of obese people with various chronic diseases, the number of patients with VLUs will increase. These patients' performance will be a significant burden on the health care system [61].

Venous leg ulcers are significantly more common in the elderly. In 13% of people, VLUs first appears before the age of 30, and 22% before the age of 40. For this reason, patients with VLUs have a reduced quality of life and varying degrees of physical disabilities. These patients suffer varying degrees of acute and chronic pain [62].

The application of modern diagnostic and therapeutic modalities in the treatment of VLUs in combination with available evidence-based data will reduce the number of patients who will not heal VLUs and who will relapse. Therefore, the use of standard methods of treatment and the use of expensive advanced therapeutic agents is of particular importance.

It is very important to have a comprehensive clinical examination at the very beginning. Subsequent non-invasive and sometimes invasive tests may be indicated for diagnosis and treatment planning. Inadequate diagnosis results in inadequate therapy.

The application of objective tests aims to confirm the diagnosis, determine the etiology of the disease, locate the anatomical site of the venous disease (superficial, deep, and perforating venous system) and the severity of the disease, or identify coexisting peripheral arterial disease [63].

Taking a good medical history is imperative of a good clinical examination. Patients with VLUs have a rich medical history and a number of concomitant comorbidities. Unfortunately, there are not enough studies that have shown the value of specific items for the anamnesis [25]. In practice, it has been shown to be very important to take all data related to the previous medical history as well as the family history and the specific aspects of the ulcer [18].

In order to monitor the healing rate of ulcers, it is very important to perform an accurate and consistent wound measurement. Wound location, area, and characteristics should be documented. Traditionally, length and width are measured in perpendicular distances of wound borders (the longest length with the greatest width at right angles). This measurement can be done manually or via digital photography. These wound measurement methods are inconsistent and sometimes inaccurate. The use of digital software is recommended. The study of Cardinal et al. showed that oval or circular ulcers initially heal better than wounds with large indentations,

multiple segments and skin swellings at the edges. VLUs documentation is important for estimating the healing rates. If in the period from 4 weeks there is no reduction in wound area by 30%, it is unlikely that VLUs will heal by week 12 [64]. Patients with VLUs that heal slowly are ideal candidates for advanced therapy.

In order to make a diagnosis, the following diagnostic procedures are recommended: ABPI and duplex venous mapping. If duplex venous mapping cannot be used to make a valid diagnosis, phlebography, venous angiotomography, and venous angioresonance are recommended [64].

The success and sensitivity of the color-flow duplex ultrasound depend on the researchers and the coefficient of variation of reflux measurements ranges from 30–45% [65]. Studies have shown that duplex diagnostics has high sensitivity and specificity in the diagnosis of superficial and deep venous leg systems [65, 66]. Today, this method represents the gold standard in the diagnosis of venous diseases, enables further classification of chronic venous insufficiency and selection of the optimal treatment of venous diseases.

ABPI test is widely applied in the diagnosis of peripheral occlusive artery disease, because of its accessibility, affordable price, lack of risk, a sensitivity of 95% and a specificity of 99% [64]. Determination of ABPI is not the most reliable in patients with diabetes mellitus because compression of the arteries may not be possible due to medial sclerosis.

Taking an ulcer biopsy is a quick, easy, and effective way to identify less common etiologies in ulcers that are unusual in appearance and where there is a reasonable suspicion of a malignant etiology. Sometimes it is necessary to take multiple biopsy specimens to get an accurate diagnosis [67].

Standard sampling for bacterial colonization has no therapeutic consequence and thus is meaningless. Wound swabs should only be taken if there are signs of infection, prior to initiating therapy, and for MSRA detection. Cultivation and eventual use of antibiotics is only indicated if there are signs of VLUs infection [68].

Successful treatment of VLUs requires a multidisciplinary team to make an adequate diagnosis, assess the condition of the vascular system and determine other factors that affect the healing of ulceration.

The basis of VLUs treatment is to reduce or eliminate the effect of venous hypertension. This is achieved through the use of compression therapy, surgical treatment of venous abnormalities, local ulcer treatment, systemic medications that aid healing and complementary measures [64].

There is relatively little data in the medical literature regarding the cleansing of venous ulcers. The results of a number of prospective and retrospective studies related to surgical debridement of VLUs have shown that this method has a certain place in treatment. The results of a prospective study showed that the presence of dense fibrosis and high levels of mature collagen in ulcer tissue samples directly positively correlates with the speed and success of VLUs healing [26].

Extensive and deep debridement of VLUs that were refractory to therapy until the absence of dense fibrosis and mature collagen in the ulceration is recommended.

The results of a number of studies have shown that there are no justifiable reasons for the use of antiseptics, in principle, cytotoxic agents. Cleaning with ordinary clean water has the same result as cleaning with isotonic sodium solution [26].

The use of dressings in the treatment of VLUs has shown a significant advantage over the classic gauze bandage in a large number of studies. Proper use of dressings is based on clinical protocols containing the etiology of ulceration, clinical assessment

#### *Perspective Chapter: Diagnosis and Treatment of Venous Leg Ulcer DOI: http://dx.doi.org/10.5772/intechopen.105676*

of ulceration (depth, size, degree of purity, contamination, surrounding skin condition, amount of exudate), presence of infection, and general patient condition [30].

Modern dressings today provide optimal physio-chemical conditions necessary for normal wound healing, preventing the development of infection, controlling exudates, reducing the number of debridements and reducing the need for more painful dressings [69, 70].

Effective compression is achieved by precise application of the bend system, which should provide mild compression at rest, but also effective compression during all types of activities. All compression therapy systems achieve this to some extent, and the choice of a bandage or socks requires selection on an individual basis.

The two main principles on which compression therapy is based are [71]:


Understanding the principles of compression therapy allows us to define the ideal compression system. The characteristics of an ideal compression system are: includes inelastic component, provides good anatomical grip, enables smooth operation and mobility, provides comfort at rest, easy to apply and adapts to the size and shape of the limbs and does not cause an allergic reaction and shows endurance.

Compression therapy systems must be compatible so that they can be effectively applied in different limb sizes and shapes, while providing therapeutic levels of compression without the risk of damage. The use of multicomponent compression systems has shown significantly better efficiency in the healing of venous ulcers compared to the use of one-component compression systems. Multicomponent compression greater than 30 mm/Hg showed, in addition to high efficiency in wound healing, a reduction in the recurrence of venous ulcerations [72, 73].

After the ulcer has healed, elastic stockings with graduated compression of the appropriate size are used, with a pressure of 30–40 mmHg. In most patients, knee pads are sufficient. In fact, socks above the knee or other compression devices that exceed the height of the knee are uncomfortable to wear and occlude the popliteal vein during knee flexion. Ankle compression >40 mmHg is rarely required. If the patient is associated with arterial insufficiency, socks that produce less pressure around the ankle joint are needed, so as not to lead to skin necrosis [71].

It should be noted that it is very important to apply surgical therapy in order to treat the underlying venous disease whenever possible. The use of surgery can improve and accelerate healing, as well as reduce the risk of recurrence [64].

Unfortunately, up to this date, no randomized studies have been performed on the use of this treatment for VLUs. The problem with the application of surgical therapy in the treatment of VLUs is the lack of valid randomized, controlled studies. Previous studies have had an uneven number of patients and different surgical techniques have been applied. None of the previous studies has shown the advantage of surgical therapy over VLUs conservative treatment.

Based on the recommendations of the Scottish guidelines, surgical therapy should not be the method of choice in the VLUs treatment (an active ulcer). Surgical therapy is also not recommended as a secondary prevention after VLUs healing [74]. The data obtained from the ESHAR study showed that there is no advantage of surgery over compression therapy in the treatment of patients with varicose veins of the lower

extremities. However, this study showed that in relation to the occurrence of disease recurrence, surgical therapy proved to be more successful [75].

The number of new technologies and use of grafting techniques used in the treatment of VLUs has increased in recent years. The future may hold micro- and pixelgrafts, spray on cells and the use of 3D printing to prefabricate vascularized grafts to assist in wound coverage.

Some of the new technologies used in the treatment of VLUs require broader evidence of clinical efficacy and can be considered as experimental therapies [76].
