Treatment of trophic ulcers

To achieve a stable positive therapeutic effect, it is more correct to set the task of treating not only and not so much a ulcerative defect as the underlying disease that led to its formation. Successful implementation of this task creates favorable prerequisites for curing the patient. A complex, differentiated treatment of trophic ulcers with effect on the etiological and pathogenetic mechanisms of ulcerogenesis is necessary. Depending on the cause of ulcers, the development of various pathogenetic syndromes and complications in complex therapy, many methods of treatment are used.

Planning the treatment of trophic ulcers must proceed from the fact that in most cases the history of the underlying disease is long. The very development of ulcers is a reliable sign of decompensation of the underlying pathology and "neglect" of the disease. Depending on the severity of the underlying and concomitant diseases, the features of the clinical course and pathomorphological changes in the area of the ulcerative defect, different tasks may face the physician. The result of treatment is persistent healing of the ulcerative defect; its temporary closure with a high risk of recurrence; reduction in size; relief of acute inflammatory phenomena in the area of ulcers; purification of the wound from necrosis; cessation of the progression of ulcerative lesions and the formation of new ulcers. In a number of cases, the elimination of a ulcerative defect has no prospects and, moreover, the probability of not only preserving the ulcer, but also its spread with the development of various complications is high. Such a situation arises in diseases with an unfavorable outcome (malignant ulcers, ulcerative defects in certain diseases of connective tissue, leukemia, radiation injuries, etc.), or in the case of an unfavorable course of the underlying disease (arterial and mixed lesions in the impossibility of vascular reconstruction, extensive "senile" ulcers, etc.).

All skin ulcers are infected. The role of the infectious factor in the pathogenesis of ulcers has not been fully determined, but it is clear that the microflora can support ulcerogenesis, and in some cases it causes the development of invasive infections and other complications (erysipelas, cellulitis, lymphangitis, etc.). The most common of the ulcers are Staphylococcus aureus, enterobacteria, Pseudomonas aeruginosa. In the case of limb ischemia, in the case of decubital, diabetic ulcer defects with high constancy, an anaerobic flora is detected. Antibacterial treatment of trophic ulcers is prescribed in the presence of ulcers with clinical manifestations of wound infection accompanied by local (profuse purulent or serous-purulent discharge, necrosis, perifocal inflammation) and systemic inflammatory changes, as well as in the development of periulcerous infectious complications (cellulitis, erysipelas, phlegmon) . The effectiveness of antibiotic therapy in these situations has been clinically proven. As an empirical antibiotic therapy, 3-4-generation cephalosporins, fluoroquinolones, are prescribed. In the presence of factors predisposing to the development of anaerobic infection, treatment of trophic ulcers includes antianaerobic drugs (metronidazole, lincosamides, protected penicillins, etc.). With clinical signs of Pseudomonas aeruginosa, ceftazidime, sulperazone, amikacin, carbapenems (meropenem and thienam), ciprofloxacin are considered the drugs of choice. Correction therapy is carried out after obtaining bacteriological data with the determination of the results of sensitivity of microflora to antibacterial drugs. The abolition of antibacterial therapy is possible after persistent relief of local and systemic signs of infectious inflammation and the transition of the ulcer to stage II of the wound process. The appointment of antibacterial treatment of trophic ulcers in patients with uncomplicated forms is in most cases not justified, since it does not reduce the healing of ulcers, but leads to a change in the microbial composition and the development of selection of strains resistant to most antibacterial drugs.

One of the main tasks in the treatment of trophic ulcers is the improvement of microcirculation, which is achieved by means of pharmacotherapy. For this purpose, hemorheologically active drugs that affect various factors of blood coagulability, prevent adhesion of platelets and leukocytes and their damaging effect on the tissue are used. Clinical studies have confirmed the effectiveness of the appointment of synthetic analogues of prostaglandin E2 (alprostadil) and pentoxifylline (in a daily dosage of 1200 mg) with microcirculatory disorders. This treatment of trophic ulcers is now recognized as standard in the therapy of arterial ulcers, as well as ulcers that have arisen against systemic connective tissue diseases and venous ulcers that can not be treated with conventional phlebotonics and compression therapy.

Methods of physical impact are widely used in the treatment of trophic ulcers. At present, a wide arsenal of modern physiotherapeutic procedures is available that have a beneficial effect on the healing processes of trophic ulcers of various genesis. Physiotherapeutic treatment improves microcirculation in tissues, contributing to stimulation of reparative processes, has anti-inflammatory, anti-edema action and a number of other effects. At the same time, most physiotherapy techniques have no evidence base based on randomized clinical trials, and therefore their purpose is empirical.

In the treatment of trophic ulcers, many different methods and means are currently used, including hyperbaric oxygenation, UV, laser irradiation of blood, hirudotherapy, plasmapheresis, lymphosorption and other methods of detoxification, the use of immunomodulators and other methods that have not undergone qualitative clinical studies. From the standpoint of evidence-based medicine, they can not be used as standard methods of treatment.

Local treatment of trophic ulcers is one of the most important areas of therapy. Wounds of any origin are unified in their biological healing laws, which are genetically determined. In this regard, the general principles of treatment are uniform for wounds of any etiology, and the therapeutic tactics of local effects depend on the phase of the wound process and its features in a particular patient. It is obvious that there are no universal dressings. Only a differentiated approach and directional effect on the wound process at various stages of treatment of ulcers, taking into account the individual characteristics of their course, allows achieving the main goal - delivering the patient from a ulcerative defect that sometimes exists for a month or a year. The art of a doctor dealing with the treatment of trophic ulcers is a deep understanding of the processes occurring in the wound at all stages of her healing, his ability to respond in a timely manner to the changes that occur during the wound process with an adequate correction of therapeutic tactics.

The optimal choice of dressings used to treat ulcers, remains one of the most important issues that largely determine the positive outcome of the disease. With the development of ulcerative skin lesions, the dressing must perform a number of important functions, without observing which healing of the ulcerative defect is difficult or impossible:

• protect the wound from contamination by its microflora;
• suppress the multiplication of microorganisms in the affected area;
• maintain the ulcer base in the wet state, preventing its drying;
• have a moderate absorbent effect, remove excess wound detachable, which otherwise leads to maceration of the skin and activation of the wound microflora, while not drying the wound;
• ensure optimal gas exchange of the wound;
• to be removed painlessly, without traumatizing the tissues.

In the first phase of the wound process, the local treatment of trophic ulcers is designed to solve the following problems:

• suppression of infection in the wound;
• activation processes of rejection of nonviable tissues;
• evacuation of wound contents with absorption of products of microbial and tissue decay.

Complete cleansing of ulcers from necrotic tissues, decrease in the amount and nature of the discharge, elimination of perifocal inflammation, reduction of the contamination of the wound by the microflora below the critical level (less than 105 cfu / ml), the appearance of granulations indicates the transition of the wound to phase II, in which it is necessary:

• provide optimal conditions for the growth of granulation tissue and migration of epithelial cells;
• stimulate reparative processes;
• protect the skin defect from secondary infection.

The physicochemical conditions in which healing takes place have a significant effect on the normal course of repair processes. The work of a number of researchers has shown the particular importance of a moist environment for the self-cleaning of the wound, the proliferation and migration of epithelial cells. It has been established that with a sufficient amount of water in the extracellular matrix, a looser fibrous tissue forms with the subsequent formation of a less coarse but more permanent scar.

One of the simplest and at the same time convenient classifications of ulcers (chronic wounds) is considered to be their separation according to color. Distinguish the wound "black", "yellow" (as its varieties - "gray" or "green" in the case of Pseudomonas infection), "red" and "white" ("pink"). Appearance of the wound, described by the color scale, sufficiently reliably determines the stage of the wound process, allows to evaluate its dynamics, to develop a program of local wound treatment. So, the "black" and "yellow" wounds correspond to the first stage of the wound process, but in the first case dry necrosis and ischemia of tissues are usually noted, and in the second - wet. The presence of a "red" wound indicates the transition of the wound process to the second stage. The "white" wound indicates the epithelization of the wound defect, which corresponds to phase III.

In the treatment of trophic ulcers of any origin, interactive dressings that do not contain active chemical, cytotoxic additives, and allow the creation of a moist environment in the wound have proved effective. The effectiveness of most interactive dressings is quite high and has a solid evidence base for most of the dressings currently used.

In the stage of exudation, the main task is to remove the exudate and clear the ulcer from purulent-necrotic masses. If possible, the toilet of the ulcerous surface is held several times a day. To this end, the sponge is washed with a saline soap solution under running water, after which the ulcer is irrigated with an antiseptic solution and drained. To prevent the dehydration of the skin surrounding the ulcer, it is applied moisturizing cream (baby cream, after shave cream with vitamin F, etc.). In the case of maceration of the skin, ointments, lotions or bolts containing salicylates (diprosalic, whitewash, zinc oxide, etc.) are applied on them.

In the presence of trophic ulcer, which is a dry, tightly fixed scab ("black" wound), treatment should be started with the use of hydrogel dressings. These dressings can quickly achieve complete delimitation of necrosis, rehydrate a dense scab with a rejection of it from the wound bed. After this, it is easy to make mechanical removal of necrotic tissues. The use of an occlusive or semi-occlusive dressing enhances the healing effect and promotes faster sequestration of necrosis. The use of hydrogels is contraindicated in the presence of tissue ischemia due to the risk of activation of wound infection.

At the stage of the "yellow" wound, the choice of means of local treatment of trophic ulcers is more extensive. This phase mainly uses drainage sorbents containing proteolytic enzymes, Tender-24, hydrogels, water-soluble ointments, alginates, etc. The choice of dressing at this stage of the wound process depends on the degree of exudation of the wound, the massiveness of the necrotic tissues and fibrinous overlap, infection activity. With adequate local and systemic antibacterial therapy, the purulent-inflammatory process is quickly resolved, the rejection of dry and moist foci of necrosis, dense fibrin films is activated, and granulations appear.

During the proliferation phase, the amount of dressings is reduced to 1-3 per week to prevent traumatization of tender granulation tissue and the emerging epithelium. In this stage, for the sanation of a ulcerous surface, the use of aggressive antiseptics (hydrogen peroxide, etc.) is contra-indicated, preference is given to washing the wound with isotonic sodium chloride solution.

When the stage of the "red" wounds is reached, the question of the expediency of plastic closure of the ulcerative defect is solved. With the rejection of skin plasty treatment is continued under bandages that are able to maintain the moist environment necessary for the normal course of reparative processes, as well as protect the granulation from trauma and, at the same time, prevent the activation of wound infection. For this purpose, preparations from the group of hydrogels and hydrocolloids, alginates, biodegradable wound coatings based on collagen, etc. Are used. The moist environment created by these preparations promotes unimpeded migration of epithelial cells, which ultimately leads to epithelization of the ulcerative defect.

Principles of surgical treatment of trophic ulcers

In any type of intervention for ulcers on the lower extremities, regional methods of anesthesia should be preferred, using spinal, epidural or conductive anesthesia. In conditions of adequate control of central hemodynamics, these methods of anesthesia create optimal opportunities for interventions of any duration and complexity with a minimum number of complications in comparison with general anesthesia.

An ulcer containing massive, deep foci of necrosis, above all, must be surgically treated, in which a mechanical removal of the non-viable substrate is performed. Indications for surgical treatment of a purulent necrotic focus in trophic ulcers:

• the presence of extensive deep necrosis of tissues remaining in the wound despite adequate antibacterial and topical treatment of trophic ulcers;
• development of acute purulent complications requiring urgent surgical intervention (necrotic cellulitis, fasciitis, tendovaginitis, purulent arthritis, etc.);
• the need to remove local necrotic tissues, usually resistant to local therapy (with necrotic tendonitis, fasciitis, contact osteomyelitis, etc.);
• the presence of an extensive ulcerative defect, requiring adequate analgesia and sanitation.

Contraindication to surgical treatment for trophic ulcers is ischemia of tissues, which is observed in patients with arterial and mixed ulcerative defects against the background of chronic obliterating diseases of lower extremity arteries, diabetes mellitus, in patients with congestive heart failure, etc. Intervention in this group of patients involves with the progression of local ischemic changes and leads to an expansion of the ulcerative defect. The possibility of necrectomy is possible only after a stable resolution of ischemia, confirmed clinically or instrumentally (transcutaneous oxygen tension> 25-30 mm Hg). Do not resort to necrectomy and in those cases where the ulcerative defect only begins to form and proceeds according to the type of formation of moist necrosis. Such intervention in conditions of severe local microcirculatory disorders not only does not contribute to the early clearance of the ulcerative defect from necrosis, but also often leads to activation of destructive processes and prolongation of the first phase of the wound process. In this situation it is advisable to conduct a course of conservative anti-inflammatory and vascular therapy and only after delimitation of necrosis and relief of local ischemic disorders to excise non-viable tissues.

Randomized trials comparing the efficacy of nekrektomii (debridement) and conservative autolytic cleansing of the wound, did not reliably reveal the superiority of this or that method. Most foreign researchers prefer conservative treatment of these wounds under different types of dressings, regardless of the time frame for achieving the result. Meanwhile, a number of experts believe that surgical treatment of necrotic ulcers performed according to indications and at the right time significantly speeds up the processes of cleansing the wound defect, quickly suppresses the symptoms of the systemic and local inflammatory response, reduces pain syndrome and is economically more beneficial than the long one, and in a number cases of unsuccessful use of local treatment of trophic ulcers.

Surgical treatment for ulcer of the lower extremities usually consists in removal of all necrotic tissue, regardless of the volume, area and type of affected tissues. In the area of the joint capsule, neurovascular bundles, serous cavities, the volume of necrectomy should be more restrained in order to avoid their damage. Carry out a thorough hemostasis by coagulation of vessels or ligation by ligatures, which should be removed after 2-3 days. The wound surface is treated with solutions of antiseptics. The most effective sanation of the ulcerative defect is observed with the use of additional methods for treating the wound using a pulsating jet of antiseptic, evacuation, ultrasonic cavitation, and treatment of the ulcer with a CO2 laser beam. The operation is terminated by applying gauze napkins impregnated with a 1% solution of iodopyron or povidone-iodine, which it is desirable to put on top of the mesh atraumatic wound cover (Jelonet, Branolind, Inadine, Parapran, etc.), which will allow properties of these dressings to make the first after surgery bandaging is almost painless.

In the transition of the wound process to phase II, favorable conditions for the use of surgical methods of treatment, aimed at an early closure of the ulcerative defect, appear. The choice of the method of surgical intervention depends on many factors related to the general condition of the patient, the type and nature of the clinical course of the underlying disease and ulcerative defect. These factors largely determine the tactics of treatment. Trophic ulcers with an area of more than 50 cm2 have a weak tendency to spontaneous healing and in the majority are subject to plastic closure. The localization of even a small ulcer on the supporting surface of the foot or in the functionally active zones of the joints makes surgical methods of treatment a priority. In the case of an arterial ulcer of the lower leg or foot, the treatment is practically unpromising without preliminary vascular reconstruction. In a number of cases, the treatment of cutaneous ulcers is carried out only with the use of conservative methods of treatment (ulcers in patients with blood diseases, systemic vasculitis, with severe psychosomatic state of the patient, etc.).

Operative treatment of trophic ulcers is divided into three types of surgical interventions.

• Treatment of trophic ulcers, aimed at pathogenetic mechanisms of ulceration, which include operations leading to a decrease in venous hypertension and the elimination of pathological veno-venous refluxes (phlebectomy, subfascial bandaging of perforating veins, etc.); revascularization operations (endarterectomy, various types of shunting, angioplasty, stenting, etc.); neuroraphy and other interventions on the central and peripheral nervous system; osteonecrectomy; excision of a tumor, etc.
• Treatment of trophic ulcers directed directly to the ulcer itself (skin plasty):
  • autodermoplasty with excision or without excision of ulcers and scar tissue;
  • excision of the ulcer with closure of the defect with the help of plastic by local tissues using acute dermotension or dosed stretching of tissues; various types of Indian skin plasty; islet, sliding and interdigested skin grafts;
  • plastic ulcers with the use of tissues from distant parts of the body on temporary (Italian dermal plastic, plastic with Filatov's stem) or a constant feeding leg (transplantation of tissue complexes on microvascular anastomoses);
  • Combined methods of skin plasty.
• Combined operations that combine pathogenetically
  • Interventions and dermal plastic surgery performed at one time or at a time
  • personal sequence.

In the foreign press, devoted to the therapy of chronic wounds, for various reasons, the conservative orientation of treatment dominates, which, apparently, is associated with the significant influence of companies that manufacture dressings. It is logical to assume the need for a reasonable combination of methods of conservative therapy and surgical treatment, the place and nature of which are determined individually, based on the patient's condition, the clinical course of the underlying disease and ulcerative process. Local treatment of trophic ulcers and other methods of conservative therapy should be considered an important stage aimed at preparing the wound and surrounding tissues for pathogenetically directed surgical intervention whenever possible with the closure of the defect by any of the known methods of skin plasty. Skin implants should be used when expecting a significant reduction in the duration of treatment, improving the quality of life of the patient, cosmetic and functional results. In those cases when the plastic of a wound defect is not shown or is impossible (a small area of a defect capable of healing itself in a short time, a 1 phase wound process, a patient's refusal from surgery, severe somatic pathology, etc.), wounds are treated only conservatively. In this situation, conservative treatment, including an adequately selected local treatment of trophic ulcers, plays a leading role.