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Lower Extremity Ulcers

Collagen and Lower Extremity Ulcers

Lower extremity ulcers are common and vary in cause. Some patients will have a combination of factors resulting in lower limb ulcers. Many of these patients will suffer from recurrent wounds throughout their lifespan, especially if the cause is not adequately addressed. For all patients with lower limb wounds, seeking appropriate and immediate care is vitally important and may require various specialists.

Physical examination should include wound assessment, pulses, leg circumferential measurements, sensation, mobility and blood work. Common diagnostic tests may include ABI, duplex ultrasound, angiography, MRI and or/skin biopsy(1). Surgical procedures may be required for some people with a goal to restore blood flow and remove necrotic tissue for wound healing.

Many of these lower extremity ulcers have typical presentations which can give an indication of the underlying issue. Venous ulcers are by far the most common lower extremity wound. In the United States, 10% to 35% of adults have chronic venous insufficiency, and 4% of those will have an ulcer (2). Venous wounds normally present with a history of varicose veins, DVT, trauma, surgery, multiple pregnancies; aching and swelling worse at the end of the day. Open areas will be seen in the inner lower calf known as the gaiter region (2). Pain is usually mild and relieved by elevating feet. Wounds will ooze and will be fairly shallow with an irregular shape. A hallmark part of treatment requires the incorporation of compression therapy to relieve the backflow from failed vessels.

Arterial wounds are ischemic ulcers due to a lack of blood flow to the area. They can be further exacerbated by smoking, intermittent claudication, and medications that promote vasoconstriction. Arterial wounds will normally present on the distal or dorsum of the foot or toes, over bony prominences normally they will have poor granulation tissue, a round punched-out appearance and fairly dry necrotic tissue. Pain can be severe, particularly at night; relieved by lowering feet below the heart(1).

Lower extremity ulcers can be complicated by mixed etiologies which complicate treatment and prolong healing. People can have multiple medical issues that can worsen lower extremity ulcers. For instance, diabetes may lead to foot ulcers, lymphedema frequently coincides with open areas on the legs, cellulitis can affect any open area. Many patients with lower extremity ulcers suffer from debilitating pain, recurrent infection, impaired work productivity and eventually poor quality of life (4).

All chronic wounds have protease imbalances which degrade the formation of extracellular matrix, impair cell migration, and reduce fibroblast proliferation and collagen synthesis. These are key processes essential to healing. The growth of new dermal tissue is a complex and dynamic process that can benefit from the use of bioactive collagen-based dressings that interact with the wound bed to mediate elevated protease activity and stimulate the production and deposition of new tissue (4). Advanced wound dressing made of triple helical Type 1 collagen plays a critical role in wound healing in expediting wound healing faster than traditional wound dressings of saline and gauze.
Collagen products facilitate homeostasis appropriate for use after serial debridement common in wound management of lower extremity ulcers. Products can be left in place for up to 7 days depending on drainage and may be appropriate for use under compressive wraps. They are non-toxic and naturally made from bovine (cattle) sources and provide a non-adherent layer that facilitates angiogenesis and protection of newly formed tissue. All of Human Biosciences’ products contain native non-hydrolyzed Type -1 bovine collagen in its purest form with three modes of delivery for KollagenTM technology. Collatek® Gel would be most appropriate for dry wound beds requiring additional moisture. SkinTemp® II Sheets would be suitable for coverage of flat shallow surfaces. Medifil® II Particles appropriately fill a cavity with irregular depths.

By Dr. Heather Flexer, DPT, CWS

References

  1. Spentzouris G, Labropoulos N. The evaluation of lower-extremity ulcers. Semin Intervent Radiol. 2009;26(4):286-295. doi:10.1055/s-0029-1242204 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036466/
  2. Bonkemeyer Millan S, Gan R, Townsend PE. Venous Ulcers: Diagnosis and Treatment. Am Fam Physician. 2019;100(5):298-305. https://pubmed.ncbi.nlm.nih.gov/31478635/
  3. Raffetto JD, Ligi D, Maniscalco R, Khalil RA, Mannello F. Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment. J Clin Med. 2020;10(1):29. Published 2020 Dec 24. doi:10.3390/jcm10010029 https://www.mdpi.com/935838
  4. Alavi A, Archer J, Coutts P. Use of an advanced collagen matrix dressing on patients with complex chronic lower extremity ulcers: A case series. SAGE Open Med Case Rep. 2021;9:2050313X211013684. Published 2021 May 13. doi:10.1177/2050313X211013684 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8127786/

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