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1 management of chronic venous leg ulcers A national clinical guidelineAugust 2010120 KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONSLEVELS OF EVIDENCE1++High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias1+Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias1 -Meta-analyses, systematic reviews, or RCTs with a high risk of bias2++ High quality systematic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal2+Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal2 - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal3 Non-analytic studies, eg case reports.

2 Case series4 Expert opinionGRADES OF RECOMMENDATIONNote: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of resultsBA body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results.

3 OrExtrapolated evidence from studies rated as 1++ or 1+CA body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; orExtrapolated evidence from studies rated as 2++DEvidence level 3 or 4; orExtrapolated evidence from studies rated as 2+GOOD PRACTICE POINTS Recommended best practice based on the clinical experience of the guideline development groupNHS Evidence has accredited the process used by Scottish Intercollegiate guidelines Network to produce guidelines . Accreditation is valid for three years from 2009 and is applicable to guidance produced using the processes described in SIGN 50: a guideline developer s handbook, 2008 edition ( ).

4 More information on accreditation can be viewed at Quality Improvement Scotland (NHS QIS) is committed to equality and diversity and assesses all its publications for likely impact on the six equality groups defined by age, disability, gender, race, religion/belief and sexual guidelines are produced using a standard methodology that has been equality impact assessed to ensure that these equality aims are addressed in every guideline . This methodology is set out in the current version of SIGN 50, our guideline manual, which can be found at The EQIA assessment of the manual can be seen at The full report in paper form and/or alternative format is available on request from the NHS QIS Equality and Diversity care is taken to ensure that this publication is correct in every detail at the time of publication.

5 However, in the event of errors or omissions corrections will be published in the web version of this document, which is the definitive version at all times. This version can be found on our web site This document is produced from elemental chlorine-free material and is sourced from sustainable Intercollegiate guidelines NetworkManagement of chronic venous leg ulcers A national clinical guidelineThis guideline is dedicated to the memory of Dr Susan MorleyAugust 2010 management of chronic venous leg ulcersisBn 978 1 905813 66 7 Published august 2010 This guideline was issued in 2010 and will be considered for review in three years.

6 The review history, and any updates to the guideline in the interim period, will be noted in the review report, which is available in the supporting material section for this guideline on the SIGN website: consents to the photocopying of this guideline for the purpose of implementation in NHSS cotlandscottish intercollegiate guidelines network healthcare improvement scotland gyle square, 1 south gyle crescent edinburgh eh12 Introduction .. Background .. Updating the evidence .. Statement of intent ..22 Key recommendations .. Treatment .. Preventing ulcer Provision of care.

7 43 Assessment .. Assessing the patient .. Assessing the leg .. Assessing the ulcer .. Re-assessment .. Criteria for specialist referral ..84 Treatment .. Introduction .. Cleansing and debridement .. Dressings .. Surrounding skin .. Compression .. Systemic therapy .. Analgesia .. Skin grafting .. Other therapies .. Venous surgery .. Lifestyle Preventing ulcer recurrence .. Graduated compression for healed venous ulceration .. Venous surgery ..196 Provision of care .. Background .. Training .. Specialist leg ulcer clinics .. Leg clubs ..21 management OF CHRONIC VENOUS LEG ULCERS7 Provision of information.

8 Checklist for provision of information .. Sources of further information .. Sample information Implementing the guideline .. Auditing current practice .. Recommendations with potential resource implications ..269 The evidence base .. Systematic literature review .. Recommendations for research .. Review and updating ..2710 Development of the guideline .. Introduction .. The guideline development group .. Consultation and peer review ..29 Abbreviations ..31 Annexes ..32 References ..38 management OF CHRONIC VENOUS LEG ULCERS11 INTRODUCTION1 BACKGROUNDV enous ulceration is the most common type of leg ulceration.

9 Sixty to 80% of leg ulcers have a venous The Lothian and Forth Valley Study examined 600 patients with leg ulceration and found that 76% of ulcerated legs had evidence of venous disease and 22% had evidence of arterial disease. Ten to 20% of cases had both arterial and venous insufficiency. Nine per cent of ulcerated legs were in patients with rheumatoid arthritis. Five per cent of the patient group had venous leg ulceration has an estimated prevalence of between and in the United ,9 Prevalence increases with Approximately 1% of the population will suffer from leg ulceration at some point in their ulcers arise from venous valve incompetence and calf muscle pump insufficiency which leads to venous stasis and hypertension.

10 This results in microcirculatory changes and localised tissue ,12 The natural history of the disease is of a continuous cycle of healing and breakdown over decades and chronic venous leg ulcers are associated with considerable morbidity and impaired quality of Leg ulcers in patients from the most deprived communities (social classes IV and V) take longer to heal and are more likely to be of this major health problem results in a considerable cost to the NHS. The cost of treating one ulcer was estimated to be between 1,298 and 1,526 per year based on 2001 prices and in the context of a trial conducted within a specialist leg ulcer THE NEED FOR A GUIDELINEE vidence of variation in both healing rates and recurrence rates of venous leg ulcers highlights the need for an updated evidence based guideline to support practice.