Related Terms

• Autolytic debridement, bed sore, bed sores, Clostridium sp., collagen, collagen matrix, cuts, debridement, decubitus ulcer, deep vein thrombosis, diabetic ulcers, DVT, electrotherapy, epithelial, epithelialization phase, extravasation, gangrene, gas gangrene, human growth factors, hydrocolloid, hyperbaric oxygen, incision wounds, incontinence, infected surgical wounds, infectious arthritis, inflammatory phase, injuries, laceration, mechanical debridement, microvascular, minor injuries, myonecrosis, necrotizing fasciitis, pressure ulcers/wound care, proliferative phase, puncture wound, remodeling phase, scrapes, scratches, sepsis, septic arthritis, skin damage caused by incontinence, skin graft healing (split thickness), skin ulcer, surgical skin flap ischemia, skin wounds, squamous, stasis leg ulcer, stitches, superficial, suture, venous insufficiency, venous skin ulcer, venous ulcer, vulnerary, wound care, wound healing.

Background

• Skin ulcers are open sores that are often accompanied by the sloughing-off (shedding) of inflamed tissue. Skin ulcers can be caused by a variety of events, such as trauma, exposure to extreme temperatures or corrosive material, or problems with blood circulation.

• Venous leg ulcers are the most common type of skin ulcer. They mainly occur just above the ankle. They usually affect older people and are more common in women. About one out of 50 people develop a venous leg ulcer at some stage in their lives. Venous leg ulcers are usually painless, but they may cause pain in some cases. Without treatment, an ulcer may become larger and cause problems in the leg, such as infection.

• Pressure ulcers, also known as decubitus ulcers or bedsores, are skin ulcers that develop on areas of the body where the blood supply has been reduced because of prolonged pressure. Pressure ulcers may occur in people confined to bed or a chair, or in those who must wear a hard brace or plaster cast. Skin ulcers may become infected, which may lead to complications such as sepsis (infection in the blood).

• Other health conditions that can cause skin ulcers include chronic venous insufficiency, diabetes, infections, and a disease of the blood vessels that supply the blood to the limbs called peripheral vascular disease.

Causes and Risk Factors

• Venous (skin) ulcer:

• Avenous skin ulcer, also called a stasis leg ulcer, is a shallow wound that develops due to venous insufficiency, a condition where the leg veins do not move blood back toward the heart normally. Venous skin ulcers typically develop on either side of the lower leg, between the ankle and calf.

• The veins in the body have valves that keep blood flowing toward the heart. In a condition called venous insufficiency, the valves are damaged and allow some blood to back up in the vein. The slowed circulation causes fluid to seep out of the overfilled veins into surrounding tissues, causing tissue breakdown and ulcers.

• Less frequently, blocked veins are a contributing factor in the development of venous skin ulcers. Veins can become blocked due to deep vein thrombosis (DVT, or a blood clot in the leg).

• Factors that contribute to venous insufficiency and increase the risk of developing venous skin ulcers include: deep vein thrombosis (DVT), which may result from a severe leg injury (such as a broken or crushed bone), or leg surgery (including knee replacement and varicose vein procedures). Deep vein thrombosis may also develop when a person does not move around for long periods (for example, if a person is paralyzed or bedridden) or is obese. DVT may develop during pregnancies, which may aggravate an existing venous problem. People with blood clotting disorders or family histories of varicose veins also have an increased risk of developing DVT.

• Pressure (decubitus) ulcers:

• A pressure (decubitus) ulcer, also known as a bedsore or pressure sore, is an area of skin that breaks down when an individual stays in one position for too long without shifting his/her weight. This often happens if an individual is bed ridden or confined to a wheelchair, even for a short period of time (such as after surgery or an injury). Constant pressure against the skin reduces the blood supply to that area, and the affected tissue eventually dies.

• A pressure ulcer starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a deep, circular wound called a crater. The most common places for pressure ulcers are over bony prominences (bones close to the skin) like the elbow, heels, hips, ankles, shoulders, back, and the back of the head. Pressure ulcers occur in approximately 9% of hospitalized patients, usually during the first two weeks of hospitalization, and in approximately 25% of nursing home residents.

• Risk factors for developing a pressure ulcer include:

• Age: The majority of pressure sores occur in people older than 70. Older adults tend to have thinner skin than younger people do, making them more susceptible to damage from minor pressure. Elderly individuals also tend to be underweight, with less natural cushioning over their bones. And poor nutrition, a serious problem among older adults, not only affects the integrity of the skin and blood vessels but also hinders wound healing. Even with optimum nutrition and good overall health, wounds tend to heal more slowly as individuals age. Also, nursing home residents have higher rates of bedsores than do people who are hospitalized or cared for at home due to immobilization and urinary incontinence.

• Conditions affecting circulation: Because certain health problems such as diabetes and vascular disease affect circulation, parts of the body may not receive adequate blood flow, increasing an individual's risk of tissue damage.

• Decreased mental awareness: Individuals whose mental awareness is lessened by disease, trauma, or medications are often less able to take the actions needed to prevent or care for pressure sores. Conditions that impair cognition, such as dementia and Alzheimer's disease, may also lead to decreased mental awareness and an increased need to prevent or care for pressure sores.

• Lack of pain perception: Individuals with a loss of sensation, such as patients with spinal cord injuries or diseases, cannot feel discomfort or the need to change positions when a bedsore is forming.

• Malnutrition: Individuals are more likely to develop pressure sores if they have poor diets, especially one deficient in protein, zinc, and vitamin C. Individuals that are malnourished are also more likely to have recurrent pressure sores, more severe infections, and slower healing wounds than are people with healthier diets.

• Smoking: Smokers have a higher incidence of pressure sores than nonsmokers. Smokers also tend to develop more severe wounds and to heal more slowly, mainly because nicotine impairs circulation and reduces the amount of oxygen in the blood. The risk increases with the number of years and cigarettes smoked.

• Urinary or fecal incontinence: Problems with bladder control can greatly increase the risk of pressure sores because the skin stays moist from urine, making it more likely to be damaged. Bacteria from fecal matter not only can cause serious local infections but also lead to life-threatening systemic complications such as sepsis, gangrene, and, rarely, a severe and rapidly spreading infection called necrotizing fasciitis.

• Diabetic ulcer:

• Diabetic peripheral neuropathy (nerve damage as a result of diabetes) causes the greatest risk of foot ulceration, due to disease of the microvascular (small blood vessels) and uncontrolled blood sugar levels. Peripheral neuropathy disables sensation in the feet so the individual is unable to sense pain or discomfort if injured in that area. This allows the ulcer to be left untreated, increasing the risk of infection.

• According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDKD), an estimated 18 million Americans (6.3% of the population) are affected with diabetes, and millions more are considered to be at risk. Of those at risk, diabetes is undiagnosed in 5.2 million people. Diabetic foot lesions are responsible for more hospitalizations than any other complication of diabetes. Among patients with diabetes, 15% will develop a foot ulcer, and 12-24% of those with a foot ulcer will require amputation. Diabetic ulcers are the most common foot injuries, accounting for 60% of lower extremity amputations in the United States.

Signs and Symptoms

• Venous skin ulcers:

• The first sign of a venous skin ulcer is the appearance of dark red or purple skin over the affected area. The skin may also become thickened and dry and itchy. Without treatment, an ulcer may form. The wound may be painful, and the individual may also have swollen and achy legs. Rashes may occur, such as contact dermatitis, on the skin around the ulcer.

• Because venous skin ulcers are a result of poor blood circulation, these wounds are often slow to heal. If an ulcer becomes infected, there may be an odor, pus draining from the wound, and increased tenderness and redness.

• One or more ulcers may develop on the leg or both legs. The outer layers of skin die and are shed (sloughed), exposing deeper tissues. Spots of white scar tissue may develop in the skin around a venous ulcer.

• If venous ulcers result from chronic venous insufficiency, the legs are swollen, and the skin is dark reddish brown and very firm (a condition called stasis dermatitis). The skin may itch, and the ulcers are usually very painful.

• Cellulitis, a type of infection of the skin, often develops around a venous ulcer. Typically, the infected skin is red, warm, swollen, and tender. Red streaks occasionally appear. Pus or fluid may leak from the ulcer, especially if infection involves tissues below the skin (such as muscle).

• Pressure ulcers:

• Bedsores fall into one of four stages based on their severity. Pressure sores are categorized by severity, from Stage I (earliest signs) to Stage IV (worst). The National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of pressure sores, has defined each stage as follows:

• Stage I: Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In African Americans, Hispanics, and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.

• Stage II: In stage II, some skin loss has already occurred, either in the epidermis, the outermost layer of skin, in the dermis, the skin's deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.

• Stage III: When a pressure ulcer reaches stage III, the damage has extended to the tissue below the skin, creating a deep, crater-like wound.

• Stage IV: Stage IV is the most serious and advanced stage. The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.

• If an individual uses a wheelchair, he/she is most likely to develop a pressure sore on the tailbone or buttocks, the shoulder blades and spine, or the backs of the arms and legs where they rest against the chair. When an individual is bedridden, pressure sores may occur on the back or sides of the head; the rims of the ears; the shoulders or shoulder blades; the hipbones, lower back, or tailbone; or the backs or sides of the knees, heels, ankles, and toes.

Complications

• Bone and joint infections: Bone and joint infections develop when the infection from a bedsore burrows deep into the joints and bones. Joint infections, known as septic or infectious arthritis, can damage cartilage and tissue within days, whereas bone infections (osteomyelitis) may develop over years if not treated. Eventually, bone infections can lead to reduced function and bone death, which may require amputation.

• Cellulitis: Cellulitis is a potentially serious bacterial infection of the skin. The most common bacteria that cause cellulitis are Streptococcus pyogenes and Staphylococcus aureus. Cellulitis appears as a swollen, red area of skin that feels hot and tender and it may spread rapidly. Skin on the face or lower legs is most commonly affected by this infection, though cellulitis can occur on any part of the body. Cellulitis may only affect the surface of the skin. However, cellulitis may also affect the tissues underlying the skin and can spread to lymph nodes and the bloodstream. Left untreated, the spreading bacterial infection may rapidly turn into a life-threatening condition.

• Necrotizing fasciitis: Necrotizing fasciitis is a rapidly spreading infection that destroys the layers of tissue that surround the muscles. Initial signs and symptoms include fever, pain, and massive swelling. Without treatment, death can occur in as little as 12-24 hours.

• Gas gangrene (myonecrosis): Gas gangrene is a rare and severe form of gangrene. Gas gangrene develops suddenly and dramatically and spreads so rapidly that changes in tissue are noticeable within minutes. The bacteria responsible for gas gangrene (Clostridium sp.) produce toxins that completely destroy affected muscle tissue and cause potentially fatal systemic problems. Amputation of the infected limb may be required.

• Sepsis: Sepsis (a blood infection) can occur from a wound such as advanced pressure sores. Sepsis occurs when bacteria from a massive infection enter the bloodstream and spread throughout the body. Sepsis is a rapidly progressing, life-threatening condition that can cause shock and organ failure.

Diagnosis

• Venous skin ulcer: The appearance of a venous leg ulcer looks different than ulcers caused by other problems such as poor circulation or nerve problems. To rule out poor circulation as a cause, it is usual for a doctor or nurse to check the blood pressure in the ankle and in the arm. The ankle blood pressure reading is divided by the arm blood pressure reading to give a blood pressure ratio called the Ankle Brachial Pressure Index (ABPI). If the ratio is low, it indicates that the cause of the ulcer is likely to be poor circulation rather than venous problems. This is very important to know as the treatments are very different. An ABPI may be checked routinely to make sure the circulation to the legs remains adequate.

• Routine blood and urine tests may also be done to rule out diseases that may cause or aggravate skin ulcers, such as anemia, diabetes, kidney failure, or arthritis.

• Pressure ulcers: Pressure sores (bedsores) are usually unmistakable, even in the initial stages, but a doctor is likely to order blood tests to check the individual's nutritional status and overall health. Other tests may include: urine analysis and culture, stool culture, and a wound biopsy. A wound biopsy is a sample of tissue is taken from wounds that do not heal or from chronic (long-term) pressure sores. The tissue may also be checked for cancer, which is a risk in individuals with chronic wounds.

Treatment

• Venous skin ulcer:

• Compression bandaging: Compression bandaging is the most important treatment for venous skin ulcers. This counteracts the raised pressure in the leg veins, which gives the best chance for the ulcer to heal. The common method is to put on three to four layers of bandages over the dressing, with the highest pressure at the ankle, and gradually decreasing towards the knee and thigh. A compression stocking over the dressing is sometimes used as an alternative, but not thought to be as good as bandaging. The bandages are re-applied every week or so when the ulcer dressing is changed. When using a compression bandage, the individual should still be able to move the ankle. It is important not to have the compression too tight or it may affect the circulation in the legs. Bandages should be removed immediately if the foot changes color or temperature or if there is increasing pain in the legs. A doctor should be consulted immediately if pain, temperature, or color of the area changes.

• Elevation and activity: When at rest, healthcare professionals recommend that individuals try to keep the leg elevated (raised) higher than the hip. This is particularly important if the leg is swollen. The aim is to let gravity help to pull fluid and blood in the right direction - towards the heart. This reduces swelling in the leg and reduces the pressure of blood in the leg veins.

• It is also recommended to try to set three or four periods per day of about 30 minutes to lie down with the leg raised. It is important not to spend too much time in bed or resting. Keeping active and performing normal activities is important. If possible, regular walks are good, but do not stand for long periods.

• When sleeping, it is important to try to keep the leg raised. Pillows under the bottom of the mattress can be used.

• Smoking cessation: Smoking cessation is important to decrease the risk of developing a venous skin ulcer. The chemicals in cigarettes may interfere with the skin healing.

• Antibiotics: Antibiotics are sometimes used for short periods if the skin and tissues around the ulcer become infected.

• Pain management: Medications for pain may be prescribed if the ulcer is painful. Medications may include non-steroidal anti-inflammatory drugs, such as ibuprofen (Motrin®), or opiates, such as hydrocodone (Vicodin®, Lortab®).

• Other treatments: Other treatments for venous skin ulcers include a healthy diet (such as increasing green, leafy vegetables and decreasing fatty foods) and surgery.

• Most venous ulcers heal within 12 weeks if treated with compression bandaging. If compression is not used and an ordinary dressing or compression stockings alone are used, healing is inhibited.

• Pressure ulcers:

• Once a pressure ulcer is identified, steps must be taken immediately to: relieve the pressure on that area by using pillows, special foam cushions, and sheepskin; treat the sore based on the stage of the ulcer - a healthcare provider will give specific treatment and care instructions; avoid further trauma or friction by powdering the sheets lightly to decrease friction in bed; And improve nutrition and other underlying problems that may affect the healing process. If the pressure ulcer is at Stage II or worse, a healthcare provider will give specific instructions on how to clean and care for open ulcers to prevent infection. Keeping the area clean and free of dead tissue is also important. A healthcare provider will give specific care directions. Generally, pressure ulcers are rinsed with a salt-water rinse to remove loose, dead tissue. The sore should be covered with special gauze dressing made for pressure ulcers. Do not massage the area of the ulcer, as massage may damage tissue under the skin. Donut-shaped or ring-shaped cushions are not recommended. They interfere with blood-flow to that area and cause complications, such as pressure sores.

• Non-surgical treatment: Treating pressure sores is challenging. Open wounds are slow to close, and because skin and other tissues have already been damaged or destroyed, healing may be imperfect. Although it may take some time, most stage I and stage II sores will heal with conservative measures. But stage III and stage IV wounds, which are less likely to resolve on their own, may require surgery.

• The first step in treating a sore at any stage is relieving the pressure that caused it. Pressure can be reduced by: changing positions often. Carefully follow a schedule for turning and repositioning - approximately every 15 minutes if in a wheelchair and at least once every two hours when in bed. If the individual is unable to change positions on their own, a family member or other caregiver may help. Using sheepskin or other padding over the wound can help prevent friction when moving.

• Using support surfaces is important. These are special cushions, pads, mattresses, and beds that relieve pressure on an existing sore and help protect vulnerable areas from further breakdown. The most effective support depends on many factors, including the individual's level of mobility, their body build, and the severity of their wound. Healthcare professionals recommend avoiding using pillows and rubber rings, which actually cause compression.

• Sleeping mattress should be low-air-loss beds or air-fluidized beds. Low-air-loss beds use inflatable pillows for support, whereas air-fluidized beds suspend the individual on an air-permeable mattress that contains millions of silicon-coated beads. These beads help cushion areas of the body susceptible to pressure sores, such as the buttocks.

• Other non-surgical treatments of pressure sores include cleaning the wound to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores should be cleaned with a saltwater (saline) solution each time the dressing is changed. Saline solution is available at a pharmacy or can be made at home by boiling 1 teaspoon of salt in 1 quart of water for five minutes. It is recommended by healthcare professionals to store the solution in a sterile container and cool before using. It is best to avoid antiseptics such as hydrogen peroxide and iodine, which can damage sensitive tissue and delay healing.

• Controlling incontinence as far as possible is crucial to helping sores heal. If the individual is experiencing bladder or bowel problems, they may be helped by lifestyle changes, behavioral programs, incontinence pads, or medications.

• To heal properly, wounds need to be free of tissue that is damaged, dead, or infected. One approach to removing dead tissue is surgical debridement, a procedure that involves using a scalpel or other instrument to remove dead tissue. Surgical debridement is quick and effective, but it can be painful. A doctor may use one or more non-surgical approaches. These include removing devitalized tissue with a high-pressure irrigation device (mechanical debridement), allowing the body's own enzymes to break down dead tissue (autolytic debridement), or applying topical debriding enzymes, such as Granulex®.

• Dressings: A variety of dressings are used to help protect wounds and speed healing. The type of dressing used usually depends on the stage and severity of the wound. The basic approach, however, is to keep the wound moist and to keep the skin surrounding the wound dry. Stage I sores may not need any covering, but stage II lesions are usually treated with hydrocolloids or transparent semi-permeable dressings that retain moisture and encourage skin cell growth. Examples of hydrocolloid dressings include Tegasorb® and Relicare®. Other types of dressings may be more beneficial for weeping wounds or those with surface debris. Contaminated sores may also be treated with a topical antibiotic cream.

• Hydrotherapy: Whirlpool baths can aid healing by keeping skin clean and naturally removing dead or contaminated tissue. Whirlpool baths used for burn treatment are specialized, stainless steel baths used by trained healthcare professionals.

• Healthful diet: Eating a nutritionally rich diet with adequate calories and protein and a full range of vitamins and minerals, especially vitamin A, vitamin C, Vitamin E, iron, and zinc, has been reported to improve wound healing. A well nourished body can produce healthful skin, which guards against breakdown.

• Surgical repair: The goals of surgical repair include improving the appearance of the sore, preventing or treating infection, reducing fluid loss through the wound, and lowering the risk of future cancer. The type of reconstruction that's best in any particular case depends mainly on the location of the wound and whether there's scar tissue from a previous operation. In general, though, most pressure wounds are repaired using a pad of muscle, skin, or other tissue that covers the wound and cushions the affected bone (flap reconstruction). The tissue is usually harvested from the individual's own body. In spite of every precaution, flap reconstruction has one of the highest complication rates of any surgery, and the recovery period is long and arduous. Individuals must have a strong social support system, optimal nutritional status, state-of-the-art resources such as a pressure-release bed, and the ability and motivation to participate in their own recovery to be a candidate for this operation.

• Other treatment options: New treatment options for wound healing include hyperbaric oxygen, electrotherapy, and the topical use of human growth factors. Growth factors, proteins that stimulate cell growth, have been approved for the treatment of diabetic ulcers but have not been approved for pressure sores to date.

Integrative Therapies

• Good scientific evidence:

• Aortic acid: Aortic extract is typically manufactured from the hearts of animals, usually sheep, cows, or pigs. There are many substances, including aortic acid in this extract. Mesoglycan, an aortic acid, is a structural component of blood vessels. In the case of chronic venous ulcers, mesoglycan may be able to improve venous health. Additional study is needed to confirm early findings.

• Reports of allergic reactions are currently lacking. Due to the heparin sulfate content of mesoglycan, patients who are allergic to heparin or heparinoid derivatives should use aortic acid cautiously. Use cautiously with blood disorders or if taking anticoagulation therapy. Use cautiously with high blood pressure or if taking antihypertension drugs. Avoid if pregnant or breastfeeding.

• Unclear or conflicting scientific evidence:

• Aloe: Transparent gel from the pulp of the meaty leaves of Aloe vera has been used topically for thousands of years to treat wounds, skin infections, burns, and numerous other dermatologic conditions. Study results of aloe on wound healing are mixed with some studies reporting positive results and others showing no benefit or potential worsening of the condition. Further study is needed. Early studies suggest that aloe may help heal skin ulcers. High-quality studies comparing aloe alone with placebo are needed.

• Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, tulips). Avoid injecting aloe. Avoid applying to open, surgical wounds or pressure ulcers. Avoid taking by mouth with diarrhea, bowel blockage, intestinal diseases, bloody stools, hepatitis, a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.

• Arginine: Arginine has been suggested to improve the rate of wound healing in elderly individuals. A randomized, controlled clinical trial reported improved wound healing after surgery in head and neck cancer patients, following the use of an enteral diet supplemented with arginine and fiber. Further research is necessary in this area before a firm conclusion can be drawn.

• Avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) and blood pressure drugs or herbs or supplements with similar effects. Blood potassium levels should be monitored. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

• Aromatherapy: Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Preliminary data suggest that aromatherapy may contribute to reduced pain intensity during dressing changes in wound care. Data are currently insufficient for forming a conclusion.

• Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with a history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.

• Calendula: Calendula (Calendula officinalis), also known as pot marigold, has been widely used on the skin to treat minor wounds, skin infections, burns, bee stings, sunburn, warts, and cancer. Calendula is commonly used topically (on the skin) for wound healing. Calendula has also been suggested as a possible treatment for venous leg ulcers. Reliable human research is necessary before a firm conclusion can be drawn.

• Avoid if allergic to plants in the Aster/Compositae family such as ragweed, chrysanthemums, marigolds, and daisies. Use cautiously in patients taking sedatives, blood pressure medications, cholesterol medications, blood sugar-altering agents, and immunomodulators. Use cautiously with diabetes and in children. Avoid if pregnant or breastfeeding.

• Chamomile: Chamomile (Matricaria recutita, Chamaemelum nobile) has been used medicinally for thousands of years and is widely used in Europe. There is promising preliminary evidence supporting the topical use of chamomile for wound healing. However, the available literature is not adequate to support the use of chamomile for this indication.

• Avoid if allergic to chamomile. Anaphylaxis, throat swelling, skin allergic reactions and shortness of breath have been reported. Chamomile eyewash can cause allergic conjunctivitis (pinkeye). Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.

• Chitosan: There is limited evidence on the effects of chitosan for wound healing. Better studies are needed.

• Avoid if allergic or sensitive to chitosan or shellfish. Use cautiously with diabetes or bleeding disorders. Use cautiously if taking drugs, herbs, or supplements that lower blood sugar or increase the risk of bleeding. Chitosan may decrease absorption of fat and fat-soluble vitamins from foods. Chitosan is not recommended during pregnancy or breastfeeding.

• Dimethylsulfoxide (DMSO): Dimethylsulfoxide (DMSO) is a sulfur-containing organic compound. DMSO occurs naturally in vegetables, fruits, grains, and animal products. Currently, there is not enough scientific evidence available for the use of topical DMSO for diabetic ulcers. More research is needed.

• Avoid if allergic or hypersensitive to DMSO. Use caution with urinary tract cancer or liver and kidney dysfunction. Avoid if pregnant or breastfeeding.

• Eucalyptus oil: Eucalyptus (Eucalyptus globulus) oil contains 70-85% 1,8-cineole (eucalyptol), which is also present in other plant oils. Limited evidence suggests that eucalyptus essential oil may be beneficial for patients with skin ulcers when combined with antibiotics. More studies are needed to confirm these early findings.

• Case reports describe allergic rash after exposure to eucalyptus oil, either alone or as an ingredient in creams. Avoid if allergic to eucalyptus oil or with a history of seizure, diabetes, asthma, heart disease, abnormal heart rhythms, intestinal disorders, liver disease, kidney disease, or lung disease. Use caution if driving or operating machinery. Avoid with a history of acute intermittent porphyria or if pregnant or breastfeeding.

• Gotu kola: Gotu kola (Centella asiatica) has a long history of use, dating back to ancient Chinese and Ayurvedic medicine. Preliminary study has demonstrated the ability of Centella asiatica extracts to promote wound healing, possibly through the stimulation of collagen synthesis. However, additional human study is needed in this area.

• Avoid if allergic to gotu kola, asiaticoside, asiatic acid, or madecassic acid. Avoid with a history of high cholesterol, cancer or diabetes. Avoid if pregnant or breastfeeding.

• Honey: Honey is a sweet, viscid fluid produced by honeybees (Apis melliflera) from the nectar of flowers. The primary studied use of honey is for wound management, particularly in promoting rapid wound healing, deodorizing, and debriding necrotic tissue. The types of wounds studied are varied; most are non-healing wounds such as chronic ulcers, postoperative wounds, and burns. Although honey has apparent antibacterial effects, more human study is needed in this area. Honey dressings have been used on leg ulcers with no apparent clinical benefit.

• Avoid if allergic or hypersensitive to honey, pollen, celery, or bees. Honey is generally considered safe in recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.

• Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. These approaches have been used for the relief of various diseases and injuries and for general well-being. Hydrotherapy has been used in patients with pressure ulcers and preliminary research suggests that daily whirlpool baths may reduce the time for wound healing. Better research is necessary in this area before a firm conclusion can be drawn.

• There is a risk of infection from contaminated water if sanitary conditions are not maintained. Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.

• Iodine: It is not clear if healing of wounds or skin ulcers is improved with the application of topical iodine solutions. Iodine solutions may assist with sterilization as a part of a larger approach to the wound healing process.

• Reactions can be severe, and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do not use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis, or tuberculosis. Use cautiously when applying to the skin because it may irritate or burn tissues. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction. Iodine is safe in recommended doses for pregnant or breastfeeding women. Avoid povidone-iodine for perianal preparation during delivery or postpartum antisepsis.

• Pantothenic acid (vitamin B5): Pantothenic acid (vitamin B5) is a component of coenzyme A (CoA), a molecule that is necessary for numerous vital chemical reactions to occur in cells. Pantothenic acid is essential to the metabolism of carbohydrates, proteins, and fats, as well as for the synthesis of hormones and cholesterol. In animal research, oral and topical pantothenic acid has been associated with accelerated skin wound healing. However, early human study results conflict. Additional evidence is necessary before a clear conclusion can be reached.

• Avoid if allergic or hypersensitive to pantothenic acid or dexpanthenol. Avoid with gastrointestinal blockage. Pantothenic acid is generally considered safe in pregnant and breastfeeding women when taken at recommended doses.

• Papain: Papain is an enzyme that breaks protein bonds and has been used in Africa for treating burns. In standard western medical care, papain-containing debridement agents are commonly used to remove necrotic tissue and slough in burns, postoperative wounds, pilonidal cyst wounds, carbuncles, trauma wounds, infected wounds, and chronic lesions, such as pressure ulcers, or varicose and diabetic ulcers. Based on available human evidence, papain may be very useful for wound debridement and for stimulating wound healing. More high quality research is needed in this area.

• Use cautiously in patients sensitive to papain. Use cautiously in patients being treated for prostatitis. Use Wobenzym®, which contains papain, cautiously, especially in those with bleeding disorders or taking anticoagulants or antiplatelets. Use cautiously as an adjuvant to radiation therapy. Avoid in patients with gastroesophageal reflux disease. Avoid in patients using immunosuppressive therapy.

• Physical therapy: Physical therapy techniques, such as laser treatment, have been used for wound care. Early evidence also suggests that high voltage stimulation or pulsed electrical stimulation may speed the healing of some types of skin ulcers. More research is needed to confirm these findings.

• Individuals with leg ulcers may need special care during physical therapy due to compromised skin integrity. A healthcare professional will determine what is best for each individual. Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported, although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

• Pycnogenol: Pycnogenol® is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster ssp. atlantica). Preliminary human data suggests that Pycnogenol® may be useful for the reduction of venous leg ulcers. Further research in well designed studies is needed before a conclusion can be made.

• Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia (low blood sugar), or bleeding disorders. Use cautiously if taking hypolipidemics (cholesterol-lowering medications), medications that may increase the risk of bleeding, hypertensive (high blood pressure) medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.

• Rose hip: Rose hips are the fruits that develop from the blossoms of the wild rose (Rosa spp.). They are typically orange to red in color, but some species may be purple or black. Rose hips contain several vitamins and minerals, including vitamin C, vitamin B1, vitamin E, calcium, zinc, and carotenoids, which may potentially promote wound healing when applied to the skin. Much larger and high quality clinical trials are needed to establish the therapeutic efficacy of rose hip and rose oil preparations in the topical treatment of surgical wounds and ulcers.

• Avoid in individuals with a known allergy/hypersensitivity to Rosa spp., its constituents, rose hip dust, or members of the Rosaceae family.

• Rutin: Rutin is an antioxidant that naturally occurs in various plants (apple, black tea, rue, tobacco, and buckwheat). Quercetin (a flavonoid found in rutin) and rutin are used as vasoprotectants (blood vessel protective) and are ingredients of numerous multivitamin preparations and herbal remedies. Rutin, in combination with compression, appears to have benefit over compression alone in the treatment of varicose leg ulcers. However, results are conflicting. Additional study is needed in this area.

• Avoid if allergic or hypersensitive to O-(beta-hydroxyethyl)-rutosides or plants that rutin is commonly found in, such as rue, tobacco, or buckwheat. Use cautiously in elderly patients. Use cautiously with skin conditions. Use cautiously if taking medications for edema, diuretics, or anticoagulation medications (e.g. heparin or warfarin). Use cautiously if pregnant or breastfeeding.

• TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. TENS is often used to treat pain, as an alternative or addition to pain medications and is often used in conjunction with acupuncture therapy. TENS has been evaluated in patients with diabetic foot ulcers and chronic ulcers of other causes. There is currently not enough reliable evidence on the use of TENS for skin ulcers to draw a firm conclusion.

• Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

• Therapeutic touch: Although some studies report an improvement in wound healing with therapeutic touch, others show no benefits.

• Therapeutic touch is believed to be safe for most people. However, it should not be used for potentially serious conditions in place of more proven therapies. Avoid with fever or inflammation, and on body areas with cancer.

• Vitamin A: In preliminary study, retinol palmitate significantly reduced rectal symptoms of radiation proctopathy, perhaps because of wound healing effects. Further research is needed to confirm these results.

• Avoid if allergic or hypersensitive to vitamin A. Vitamin A toxicity can occur if taken at high dosages. Use cautiously with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may be at an increased risk for lung cancer or heart disease. Vitamin A appears safe in pregnant women if taken at recommended doses; however, vitamin A excess, as well as deficiency, has been associated with birth defects. Excessive doses of vitamin A have been associated with central nervous system malformations. Use cautiously if breastfeeding because the benefits or dangers to nursing infants are not clearly established.

Prevention

• Venous leg ulcers commonly recur after they have healed. To prevent this, individuals should wear support (compression) stockings during the daytime for at least five years after the ulcer has healed. This counteracts the raised pressure in the veins that causes venous leg ulcers. A new stocking should be purchased about every six months, as the elastic tends to degrade.

• There are different classes (strengths) of compression stockings - class I, II, and III. The higher the class (class three), the greater the compression. Ideally, healthcare professionals recommend that patients with venous leg ulcers wear class three stockings. However, some people find class three stockings too tight and uncomfortable. In such cases, class two may be fine; it is still best to wear some sort of compression stocking than none at all.

• Underlying conditions, such as diabetes, should be controlled. A healthcare provider will work with the individual to help control daily blood sugar levels.

• If bedridden or immobile with diabetes, circulation problems, incontinence, or mental disabilities, healthcare providers recommend that the individual be checked for pressure sores every day. Also, look for reddened areas that, when pressed, do not turn white. It is important to look for blisters, sores, or craters. In addition, take the following steps: change position at least every two hours to relieve pressure; use items that can help reduce pressure (such as pillows, sheepskin, foam padding, and powders from medical supply stores); eat healthy, well-balanced meals; exercise daily, including range-of-motion exercises for immobile patients; and keep the skin clean and dry. Incontinent people need to take extra steps to limit moisture in the genital area.

• Individuals with diabetes should check their feet daily for blisters, sores, or other wounds in order to prevent serious infection and possibly amputations.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

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9. National Institute of Allergy and Infectious Diseases. www3.niaid.nih.gov.

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