Leg ulcers: Recommendations.

Sir,

The article summary of recommendations for leg ulcers by S Dogra and R Sarangal[1] was very informative. The authors need to be complimented for a very detailed and comprehensive account of summary recommendations for leg ulcers. As has already been brought out earlier, an accurate history and a meticulous clinical examination are of value in identifying the etiology and further management of the ulcer.

The role of ankle brachial pressure index in initiating compression therapy for managing the ulcer has been lucidly expressed. A quantitative bacterial culture is more specific than swabbing and should be performed once wound infection is suspected.[2] Quantitative biopsies containing greater than 105 organisms/g of tissue are considered significant, and systemic antibiotic therapy should be then considered. The exception to this rule is β-hemolytic streptococcus, which is harmful at any level in the wound tissue and should be considered a contra-indication for any form of formal coverage till it is completely eradicated from the wound.

Debridement is essential for any wound healing and has been described in some detail. Dressings should maintain a moist environment as epithelization occurs best then. The role of pain relief has also been covered well. Quality-of-life indices improve only when the patient is pain-free.

Indications for surgical control also have been discussed explicitly. Within the famous the effect of surgery and compression on healing and recurrence (ESCHR) trial, recurrence rates for patients treated with compression and venous surgery were 12% at 1-year and 31% at 4 years. These were significantly lower than recurrence rates for patients treated with compression alone (28% at 1-year and 56% at 4 years).[34] Several surgical procedures have been advocated for the healing and prevention of venous ulcers such as crossectomy, saphenous stripping, perforator interruption or subfascial endoscopic perforator surgery, and endovascular laser and radiofrequency procedures. The latter have been used to treat venous insufficiency, but few comparative studies to venous surgery have been performed. Split-thickness skin grafting for coverage of the ulcer has a high rate of initial success, but recurrence rates are high.[5]

Adjunctive therapy has also been covered thoroughly. The important agents for the future of wound healing may be stem cells as has also been brought out elsewhere in the issue. Numerous animal and human studies in human wounds have shown that mesenchymal stem cells (MSCs) can augment wound closure. Still, the primary contribution of MSCs to cutaneous regeneration and the long-term systemic effects of MSCs are yet to be established. In addition, we need to determine whether other types of stem/progenitor cells will be more effective. Therefore, more randomized controlled clinical trials need to be undertaken.

Leg ulcers are responsible for considerable morbidity and significantly contribute to the escalation in the cost of health care. Managing the leg ulcer is indeed a tough challenge for the wound-care provider, and the patient himself. This process needs a diligent and committed multi-disciplinary team approach for a beneficial outcome.