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Paulton
PODIATRY clinic

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Leg wounds and why they often aren't healing as they should


Caution - graphic images of wounds below. The following is my professional opinion based on over 20 years practice which has included considerable work with ulcers. This explanation is specifically about leg injuries turning into ulcers, it does apply to elderly legs in poor condition but does not necessarily apply to long standing and deep true venous ulcers (note just because you have varicose veins it does not always mean your ulcer is "venous" even if you've been told it is), legs with lymphoedema or others with underlying causes of the ulceration that might need to be addressed as well or it might actually be unable to heal (contact the clinic if unsure). Its a fairly long overview of the situation but I hope easy to understand.

Why Podiatry should be involved

As podiatrists are known mainly for working on feet it surprises many to learn our expertise covers the body to the hip. I expect for no other reason than the NHS podiatry service is under-funded and over-stretched doing feet, NHS podiatry is not currently involved with caring for wounds on legs. The job is usually undertaken by district and GP practice nurses though these days Health Care Assistants are sometimes tasked with the complex challenge even on high risk diabetic patients.

Podiatry has significant advantages in that we have training and experience of treating diabetic foot wounds which can be far more challenging than leg wounds. They occur on feet that continue to be put in shoes and walked on, there is usually reduced sensation and poor circulation at the very end of the body and the wounds are often in awkward positions between toes or on bony prominences. All this means each wound presents its own set of challenges to overcome. This requires us to keep our approach flexible and have a range of methods to choose from. Leg wounds by comparison are relatively simple to manage but its possible this has led to too much of a one size fits all approach, following "THE leg ulcer protocol" when it is not really that simple.

Although wound management is a fundamental part of podiatry education not an add-on, there is variety within the profession. Many podiatrists like myself have had focused exposure to wound management while some have had more of a passing acquaintance. Still the minimum Standards of Proficiency as set by the Health and Care Professions Council state that every podiatrist “be able to carry out mechanical debridement [cutting away with a scalpel] of intact and ulcerated skin”. [ref]

We also have materials and dressings that are not available to NHS nurses, particularly the padding to relieve pressure. And critically we spend most of our working days using a scalpel on patients who can feel what we are doing. Our necessary deftness and continual practice with that instrument is essential for debriding wounds without damaging them, that is clearing away the dead material and debris from healing which if left in place will slow or prevent healing.

How the NHS method of leg wound care is failing

It is my opinion that due to lacking these things the usual NHS treatment of leg wounds has led to a huge number of minor leg injuries unnecessarily developing into long term leg ulcers. It is so common that it seems to be expected and accepted that any leg wound takes multiple months or years to heal. That outcome isn’t considered to be poor, just normal, and the method of treatment isn’t questioned. Or quite possibly it can’t be improved without scalpel use and the limited materials available to the people currently tasked with treating them, so it is just accepted.

There are a number of aspects of the NHS leg ulcer method that a podiatrist wouldn’t do. For instance applying pressure directly onto a wound is the opposite of good practice in wound care as we understand it. Pressure relief is critical. In fact ‘negative pressure wound therapy’ technique, creating a vacuum over the ulcer, is sometimes used for diabetic foot ulcers that have become very chronic. For more normal situations just removing pressure is enough though.   

Usually, the NHS nurse led treatment aims to keep the wound always wet. It is long established that moist is better than totally dry but when honey is so commonly applied to already heavily exuding wounds it seems the difference between slightly moist and wet has been lost in translation. Foam dressings are applied with the intention of absorbing excess fluid coming from a wound, but then honey is added. As well as adding to the volume of fluid the thick viscous honey will block the pores of the foam dressing preventing any wound drainage. The wound and skin around it becomes macerated (soggy) which can damage it to the point where it breaks down further and the ulcer gets larger. Honey has been shown to have some antibacterial qualities, but is the wound even infected? Is it actually too dry and needs to be more wet? Often it is applied without any particular rationale and when it is applied innaprpriately it can cause more harm than good.

Presumably the desire to always keep the wound wet stems from the inability to use scalpels to debride wounds. Wounds do need to scab over at some point but if they do it too early or while infected it can trap toxic debris and allow fluid pressure to build up both of which damage the wound. A podiatrist carefully debrides the debris with a scalpel each weekly visit (painlessly in most cases) but lacking a scalpel a nurse would have no way of removing it. For that reason there is some logic in aiming to keep the wound wet but there are two major problems with that. The first is that scrubbing at the wet wound with gauze to remove the debris, as is done, will set healing back by damaging the delicate granulation tissue (the building blocks that later form into new skin) and the second problem is that at some point it needs to scab over before it can heal. Keeping it perpetually wet will hold the healing at that pre-scabbing stage and ergo it is a non-healing wound, otherwise known as “an ulcer”.

Further confounding things is an awful dressing that has become universally used in the NHS and care homes called “Allevyn Gentle Border”. Its single undeniable benefit is that it is quick to use. It has an adhesive across the entire dressing including a border which is halfway up the height of the foam so when pressed down it compresses the foam which then tries to expand and pushes into the skin. Pressure on the healing wound reduces blood circulation, compressed foam doesn’t absorb fluid and anything placed beneath the dressing is pushed into the delicate granulation tissue. In most cases various gauze dressings are used underneath the Allevyn (Honey, Inadine or silver usually) which are pressed into the granulation tissue leaving an appearance as though the treatment is trying to tenderise the wound base.

Below is a recent patient who came for foot care unaware that we treat leg ulcers. The condition of the wound is very typical whether after a couple of months of NHS treatment as in this case or years, with no real progress. The usual Allevyn dressing had been applied, pressing a further gauze dressing into the flesh. The square dent of the Allevyn is visible, as is the general inflammation of the surrounding skin.

The close up shows the damaged criss cross marking caused by the gauze on the new skin that is trying to heal and the soggy area to the left. Pictures of the wound after a few weeks of standard podiatry care are further down the page. (pictures displayed with permission of the patient)

It is known that a wound with more inflammation produces more fluid (exudate) than one with less inflammation. Looking at the picture above its not hard to imagine much of the inflammation is due to the jamming of rough gauzes into the wound bed. It would be no wonder if the body is trying to flush out the foreign material that is causing the inflammation. Exudate dries to form the scab and there must be a feedback mechanism to stop the flow once the scab is formed. If the scab is not allowed to form the excretion is never turned off. When I take over the treatment, remove everything hard from direct contact with the wound and allow it to begin scabbing over the excessive fluid production usually stops within a few days.

While gauze and other material is pressed into the wound base and a large amount of fluid is coming from it a dressing like Allevyn Gentle Border can seem like a good idea because it stops the fluid leaking out of the dressing. Again there is some partial logic because a leaking dressing can transmit bacteria into the wound, and it is more likely to fall off if it can leak out of the edges. However there is harm in having the pressure of the somewhat toxic fluid build up and held in the wound base. It’s a situation where one poor choice leads to having to choose between the best of two more bad choices. The real answer is to not have an excessively wet wound by removing everything from the wound bed and letting it dry in a managed way. Again though when that happens if they can’t use a scalpel to cut away the dry debris that forms, that debris creates its own problems and around the circular argument goes back to keeping it wet at all times.

The only logical conclusion that can be drawn is that scalpel use is essential and wound management is a job that should be done by those most proficient with scalpels.

“Regular, local, sharp debridement using a scalpel or forceps is considered the ‘gold standard’ (Wounds International BPG, 2013) and provides a rapid and effective method of wound debridement” [ref]

Another confounding issue… The manufacturer claims that Allevyn Gentle Border is shower proof. Perhaps because of the expectation that it will be many months to heal, usually no attempt is made to convince the patient to keep the dressing dry while showering. That’s a conversation that takes a lot of time with some patients and some patients never manage to keep it dry for various reasons. An infection following a soaking can set back healing by weeks. So when a manufacturer promotes their dressing as being shower proof the easiest thing to do is use that for everyone including the ones who would have listened and kept a more suitable dressing dry. They claim it is breathable but anyone who has used this dressing can see it bulging with fluid when the patient returns. Much better is a truly breathable lighter foam covering a drier wound on a patient who has had the time spent to educate them on the need to keep the dressing dry at all times. Specially designed leg covers are available to enable showering.

Some nurses and carers will wash a patient's leg, usually with Aqueous Cream, including the open ulcer and then reapply a dressing. This is also something a podiatrist would never do. Wounds that heal in small steps forwards must be treated with extreme care as any damage will undo the progress that has been made since the last treatment. An example of this thinking is when podiatrists will warm saline to body temperature before using it to flush a wound. Even a temporary reduction in blood flow in the wound from a cold shock is best avoided, all the small things add up to faster wound healing.

If you're thinking a lot of this is common sense...

The funny thing is we all know a lot of this. We’ve all had a small cut on our hand made soggy by a sweaty Elastoplast and seen it get better once we let the air get to it. Its not that simple with larger wounds, we have to keep the bacteria out and protect it from knocks and dirt so can’t just open it to the air. But having some padding around it to lift off a light foam dressing creates an air gap and allows space for the body to get to work healing the wound. After all, dressings never heal wounds, the body does, if its not prevented. If it is a simple wound it might just need that space to heal, if not it might need some special products to reduce slough (the gunky yellow matter that you see in the first picture above) and careful debridement over a few weeks until it can be left to heal by itself.

The podiatry difference:

One week after the initial visit, after debridement. The surrounding skin is looking much happier and the wound is reduced in size. At the initial treatment I'd used semi-compressed wool felt to pad around it and applied a fantastic material called Iodoflex (ironically made by the same company that make the dreadful Allevyn Gentle Border) you can see it has removed nearly all of the slough and the wound is healing well. I use a less is more approach and try to put nothing on as soon as possible, healing can actually be slowed by applying antiseptics every time, but with a little slough left I applied Iodoflex again. Over the Iodoflex I used a light foam dressing called Lyofoam which is more absorbent and breathable than Allevyn. I hold it all in place with a hypoallergenic breathable medical tape called Mefix which I am careful to pat down without any pull or compression on the foam. If the skin is particularly sensitive or thin I will use Opsite Spray around the wound to form a barrier between the skin and the dressing adhesive, to protect the skin.

The following week after debridement it is clearly much reduced in size again. It is clear that the leg was perfectly capable of healing and it was being held back by the previous dressings. This time I felt that there was no need for anything on the wound. I used felt to pad around it and a Lyofoam dressing to bridge over the top creating a protected environment with an air gap and nothing pressing into the wound or likely to become entangled in the new skin which would then be damaged when the dressing was removed.

End of the 3rd week after lighter debridement it has nearly healed and I expected there would be no need for debridement the following week so applied the felt and Lyofoam and advised the patient to leave it on as long as possible. It will then scab over with a healing scab and in time that will come off naturally when the wound is fully healed. If I hadn't stepped in it is almost certain it would still look the same as the first pictures on the page.

The next time I saw the patient it was fully healed

healed

Another patient:

Above you can see the typical dressing with the gauze, dent in the skin and sloughy base. The skin around the wound is red with inflamation. The dark staining is from previous infection and will remain after this wound has healed. This was being treated for months by the RUH showing that the protocol is the same whether in a GP surgery or NHS hospital.

Below after one week the inflamation is nearly gone. The wound scabbed over and after debridement, which was essential to remove the remaining slough, there is a nice clean wound with a granulating base ready to heal.

Unfortunately, it’s not as simple as asking your nurse to follow the same dressing method I've described or doing it yourself. These pictures were taken after debridement with a scalpel, if someone were to do this process without the ability to debride the hard plaque of material that forms it would trap toxic debris and could create a deeper abscess under the plaque. It also takes experience to know when to debride and when it should be left. Recently I saw a diabetic patient with poor circulation who was being seen by a Health Care Assistant, she'd mistaken a plaque of necrotic skin (gangrene) for a healing scab and reassured the patient it was healing nicely. By the time I saw it there was little I could do to help outside of a hospital setting. That case is what has prompted me to actively promote my services in this area.

We have a bizarre situation in the UK where minimally trained health care assistants are being charged with this job while perfectly suited podiatrists are almost never involved. As I said at the beginning, I believe this is purely because of the drastically under funded and under staffed NHS podiatry service but there is no reason why private podiatry shouldn't be front and center with leg wound care, as podiatry is with diabetic foot wound care.

What is the cost of private treatment?

This is just standard podiatry work so the cost is minimal, at Paulton Clinic £40 an appointment plus the cost price of dressings which for a single ulcer over a few weeks could be an additional £15-25. Usually 3 to 4 appointments are enough to heal a superficial wound that is just being prevented from healing, so all in £120 to £150.

If there are more than one and it can't be done in a single appointment a double appointment might have to be charged for but you will be informed when you come for the first treatment. If there are significant underlying health problems or it has become a deep chronic ulcer it will take longer and unfortunately in rare cases there are some ulcers that may never heal, in which case I am sometimes unable to offer treatment. At the initial assessment estimation of these things can be given.

When allowed to, the body has an amazing ability to heal. A foot or leg that was healthy before an injury usually will heal well and surprisingly quickly regardless of how bad the ulcer has got.

Changing providers

The process of changing care providers is as simple as booking with us and canceling your next appointment with whoever you were seeing. Its really your choice and you do not need to take anyone's permision. Unfortunately the communication between professions is lacking and a lot of doctors and nurses have no idea podiatry covers legs. Despite most GP practices having a policy of mandatory referral of diabetic foot wounds to podiatry many fail to realise the same skills apply just as well a few inches higher up the leg. Feel free to direct them to this page.

For that reason though some NHS providers might encourage you to stay with them despite their lack of progress. In a lot of cases you will be reassured that the ulcer is making progress when there is no change to see. Have a look at the pictures on this page, for a similar superficial wound you should see visible progress happening week on week. It is really up to you to decide if you want to try a different technique privately or stay with the NHS. If you feel uncomfortable or fear offending someone you don’t need to justify where you are going, you can phone to cancel your next appointment and most people have reported their surgery did not chase them up when they didn't return. If they do contact you after it's healed though feel free to tell them what made the difference as it might help someone else.

 

Some testimonials from patients

Wanted to say how pleased I am that you were able to hasten the healing of my leg wound. Following the procedure to remove the carcinoma from my leg at southmead I was having it dressed twice weekly by gp surgery without showing any signs of healing in 6 weeks. After just 3 visits to you it improved and now is nicely healed. Thank you.

Mrs Celia Elvin
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My elderly friend had an ulcer on her leg for almost two years and was being treated weekly and sometimes twice weekly by local nurses who tried various methods including manuka honey. She also attended Mr. Thomson's podiatry clinic on approximately 6 weekly intervals and on one occasion Mr Thomson noticed her bandage which was loose and he offered to re-dress her leg. Seeing what was being done he suggested an alternative treatment which seemed to help. However on her next visit to the nurses they once again used the honey and it deteriorated again. Finally Mr. Thomson treated her ulcer exclusively and it healed up after just 3 treatments. 

Mrs V Maule
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Due to a few falls I had a wound on the front of one of my legs. I was back and forth twice a week to the doctors surgery for two months having nurses dressing it with honey, just making it wetter rather than drying it out.

Mr Thompson spotted it on one of my foot appointments and asked if he could take a look. He was concerned at how wet the wound was and redressed it.

Soon the wound showed signs of healing and within three weeks was as good as new. 

Thank you Mr Thompson for all your help. 

Yours Sincerely Sue

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I started attending Paulton Podiatry Clinic because I had an ulcer that wouldn't heal for over a year. After numerous visits to my GP surgery no one made the link to my pre-existing health conditions (neuropathy) or even diagnosed it as an ulcer. On visiting Paulton Podiatry Clinic, it was immediately identified as an ulcer and I was given the correct dressing as well as really constructive advice on what do to and not to do. I was surprised how contradictory it was to advice I had been given at my GP surgery and it was clear that my ulcer would have never healed properly if at all had I not seen Mr Thomson. After a few visits, the ulcer was fully healed within 5 weeks. This was 8 years ago and thanks to the ongoing care I receive at Paulton Podiatry, the ulcer has never returned.

Attending Paulton Podiatry Clinic regularly has effectively prevented new ulcers and stopped my condition impacting my life - I'm still able to run around after my little girl and for that I'm very grateful!

Mrs K Ring
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2022