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 the ulcer defect, but the underlying disease that led to its formation. Successful implementation of this task creates favorable conditions for the patient's recovery. Comprehensive, differentiated treatment of trophic ulcers with an impact on the etiological and pathogenetic mechanisms of ulcerogenesis is necessary. Depending on the cause of the ulcer, the development of various pathogenetic syndromes and complications, many treatment methods are used in complex therapy.

When planning the treatment of trophic ulcers, it is necessary to proceed from the fact that in most cases the anamnesis of the underlying disease is long. The development of the ulcer itself is a reliable sign of decompensation of the underlying pathology and the "neglect" of the disease. Depending on the severity of the underlying and concomitant diseases, the characteristics of the clinical course and pathomorphological changes in the area of the ulcer defect, the doctor may face various tasks. The result of the treatment is stable healing of the ulcer defect; its temporary closure with a high prognosis for the risk of relapse; reduction in size; relief of acute inflammatory phenomena in the ulcer area; cleansing the wound from necrosis; cessation of the progression of ulcerative lesions and the formation of new ulcers. In some cases, the elimination of the ulcer defect has no prospects and, moreover, there is a high probability of not only the preservation of the ulcer, but also its spread with the development of various complications. This situation occurs in diseases that have an unfavorable outcome (malignant ulcers, ulcerative defects in some connective tissue diseases, leukemia, radiation damage, etc.), or in the case of an unfavorable course of the underlying disease (arterial and mixed lesions when vascular reconstruction is impossible, 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 has been found that microflora can support ulcerogenesis, and in some cases causes the development of invasive infections and other complications (erysipelas, cellulitis, lymphangitis, etc.). Staphylococcus aureus, enterobacteria, and Pseudomonas aeruginosa are most often isolated from ulcers. In the case of limb ischemia, decubital, and diabetic ulcerative defects, anaerobic flora is consistently detected. Antibacterial treatment of trophic ulcers is prescribed in the presence of ulcers with clinical manifestations of wound infection, accompanied by local (abundant purulent or serous-purulent discharge, necrosis, perifocal inflammation) and systemic inflammatory changes, as well as in the case of periulcerous infectious complications (cellulitis, erysipelas, phlegmon). The effectiveness of antibacterial therapy in these situations has been clinically proven. As an empirical antibacterial therapy, cephalosporins of the 3rd-4th generation, 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.). In case of clinical signs of pseudomonas infection, the drugs of choice are ceftazidime, sulperazone, amikacin, carbapenems (meropenem and tienam), ciprofloxacin. Therapy is adjusted after obtaining bacteriological data with determination of the results of microflora sensitivity to antibacterial drugs. Cancellation of antibacterial therapy is possible after persistent relief of local and systemic signs of infectious inflammation and transition of the ulcer to stage II of the wound process. Prescribing antibacterial treatment of trophic ulcers in patients with uncomplicated forms is not justified in most cases, since it does not reduce the healing time 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 considered to be the improvement of microcirculation, which is achieved with the help of pharmacotherapy. For this purpose, hemorheologically active drugs are used that affect various blood coagulation factors, preventing the adhesion of platelets and leukocytes and their damaging effect on tissues. Clinical studies have confirmed the effectiveness of prescribing synthetic analogues of prostaglandin E2 (alprostadil) and pentoxifylline (at a daily dose of 1200 mg) for microcirculatory disorders. This treatment of trophic ulcers is currently recognized as standard in the treatment of arterial ulcers, as well as ulcers that have arisen against the background of systemic diseases of connective tissue, and venous ulcers that are not amenable to conventional therapy using phlebotonics and compression therapy.

Methods of physical impact are widely used in the treatment of trophic ulcers. Currently, a wide range of modern physiotherapeutic procedures is available that have a beneficial effect on the healing processes of trophic ulcers of various origins. Physiotherapeutic treatment improves microcirculation in tissues, facilitating the stimulation of reparative processes, has an anti-inflammatory, anti-edematous effect and a number of other effects. At the same time, most physiotherapeutic methods do not have an evidence base based on randomized clinical trials, and therefore their appointment is empirical.

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

Local treatment of trophic ulcers is one of the most important areas of therapy. Wounds of any origin are uniform in their biological laws of healing, which are genetically determined. In this regard, the general principles of treatment are the same for wounds of any etiology, and the treatment tactics of local action depend on the phase of the wound process and its characteristics in a particular patient. It is quite obvious that universal dressings do not exist. Only a differentiated approach and targeted action on the wound process at various stages of ulcer treatment, taking into account the individual characteristics of their course, allows achieving the main goal - ridding the patient of an ulcer defect that sometimes exists for more than one month or year. The art of a doctor treating trophic ulcers consists in a deep understanding of the processes occurring in the wound at all stages of its healing, his ability to promptly respond to changes in the course of the wound process with adequate correction of treatment tactics.

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

• protect the wound from contamination by microflora;
• suppress the proliferation of microorganisms in the affected area;
• keep the base of the ulcer moist to prevent it from drying out;
• have a moderate absorbent effect, remove excess wound discharge, which otherwise leads to maceration of the skin and activation of wound microflora, while not drying out the wound;
• ensure optimal gas exchange in the wound;
• be removed painlessly, without damaging the tissue.

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

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

Complete cleansing of the ulcer from necrotic tissue, reduction in the amount and nature of discharge, elimination of perifocal inflammation, reduction of wound microflora contamination below the critical level (less than 105 CFU/ml), the appearance of granulation 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 normal course of reparative processes is significantly affected by the physical and chemical conditions in which healing occurs. The work of a number of researchers has shown the special importance of a moist environment for wound self-cleaning, proliferation and migration of epithelial cells. It has been established that with a sufficient amount of water in the extracellular matrix, looser fibrous tissue is formed with the subsequent formation of a less rough but more durable scar.

One of the simplest and at the same time convenient classifications of ulcers (chronic wounds) is considered to be their division by color. A distinction is made between "black", "yellow" (as its varieties - "gray" or "green" in the case of pseudomonas infection), "red" and "white" ("pink") wounds. The appearance of the wound, described by the color scheme, quite reliably determines the stage of the wound process, allows you to assess its dynamics, develop a program for local wound treatment. Thus, "black" and "yellow" wounds correspond to stage I of the wound process, however, in the first case, dry necrosis and tissue ischemia are usually noted, and in the second - wet. The presence of a "red" wound indicates the transition of the wound process to stage II. A "white" wound indicates epithelialization of the wound defect, which corresponds to phase III.

Interactive dressings that do not contain active chemical or cytotoxic additives and that allow a moist environment to be created in the wound have proven themselves well in the treatment of trophic ulcers of any origin. The effectiveness of most interactive dressings is quite high and has a solid evidence base for most dressings currently in use.

At the exudation stage, the main task is to remove the exudate and cleanse the ulcer from purulent-necrotic masses. If possible, the ulcer surface is washed several times a day. For this purpose, the ulcer is washed with a sponge with a soap solution under running water, after which the ulcer is irrigated with an antiseptic solution and dried. To prevent dehydration of the skin surrounding the ulcer, a moisturizing cream is applied to it (baby cream, aftershave cream with vitamin F, etc.). In case of maceration of the skin, ointments, lotions or chatterboxes containing salicylates (diprosalik, belosalik, zinc oxide, etc.) are applied to them.

In the presence of a trophic ulcer, which is a dry, tightly fixed scab ("black" wound), it is advisable to begin treatment with the use of hydrogel dressings. These dressings allow for a fairly rapid achievement of complete delimitation of necrosis, rehydration of the dense scab with its rejection from the wound bed. After this, it is easy to mechanically remove necrotic tissue. The use of an occlusive or semi-occlusive dressing enhances the therapeutic 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 "yellow" wound stage, the choice of local treatment for trophic ulcers is wider. In this phase, drainage sorbents containing proteolytic enzymes, "Tender-vet 24", hydrogels, water-soluble ointments, alginates, etc. are mainly used. The choice of dressing at this stage of the wound process depends on the degree of wound exudation, the massiveness of necrotic tissue and fibrinous deposits, and the activity of the infection. With adequate local and systemic antibacterial therapy, the purulent-inflammatory process resolves fairly quickly, the rejection of dry and wet foci of necrosis, dense fibrin films is activated, and granulations appear.

During the proliferation phase, the number of dressings is reduced to 1-3 per week to prevent trauma to the delicate granulation tissue and emerging epithelium. At this stage, the use of aggressive antiseptics (hydrogen peroxide, etc.) is contraindicated for the sanitation of the ulcer surface; preference is given to washing the wound with an isotonic sodium chloride solution.

When the "red" wound stage is reached, the question of the advisability of plastic closure of the ulcer defect is decided. If skin plastic surgery is refused, treatment is continued under dressings that are capable of maintaining a moist environment necessary for the normal course of reparative processes, and also protect granulations 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 dressings based on collagen, etc. are used. The moist environment created by these preparations promotes unimpeded migration of epithelial cells, which ultimately leads to epithelialization of the ulcer defect.

Principles of surgical treatment of trophic ulcers

In any type of interventions for ulcers on the lower extremities, preference should be given to regional methods of anesthesia using spinal, epidural or conduction anesthesia. Under conditions of adequate control of central hemodynamics, these methods of anesthesia create optimal opportunities for performing interventions of any duration and complexity with a minimum number of complications compared to general anesthesia.

An ulcer containing massive, deep foci of necrosis must first undergo surgical treatment, which involves mechanical removal of the non-viable substrate. Indications for surgical treatment of a purulent-necrotic focus in a trophic ulcer:

• the presence of extensive deep tissue necrosis that persists in the wound despite adequate antibacterial and local 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 (in necrotic tendinitis, fasciitis, contact osteomyelitis, etc.);
• the presence of an extensive ulcerative defect requiring adequate pain relief and sanitation.

A contraindication to surgical treatment of trophic ulcers is tissue ischemia, which is observed in patients with arterial and mixed ulcerative defects against the background of chronic obliterating diseases of the arteries of the lower extremities, diabetes mellitus, in patients with congestive heart failure, etc. Intervention in this group of patients entails the progression of local ischemic changes and leads to the expansion of the ulcer defect. The possibility of performing necrectomy is possible only after persistent resolution of ischemia, confirmed clinically or instrumentally (transcutaneous oxygen tension> 25-30 mm Hg). Necrectomy should not be resorted to in cases where the ulcer defect is just beginning to form and proceeds according to the type of formation of wet necrosis. Such intervention in conditions of severe local microcirculatory disorders not only does not contribute to the fastest cleansing of the ulcer defect from necrosis, but also often leads to the 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 limiting necrosis and stopping local ischemic disorders, excise non-viable tissue.

Randomized studies comparing the effectiveness of necrectomy (debridement) and conservative autolytic wound cleansing have not reliably revealed the superiority of one or another method. Most foreign researchers prefer conservative treatment of these wounds under various types of dressings regardless of the time it takes to achieve the result. Meanwhile, a number of experts believe that surgical treatment of a necrotic ulcer, performed according to indications and at the right time, significantly accelerates the process of wound defect cleansing, quickly relieves symptoms of systemic and local inflammatory response, reduces pain syndrome and is more cost-effective than long-term, and in some cases unsuccessful, use of local treatments for trophic ulcers.

Surgical treatment of lower limb ulcers usually involves removing all necrotic tissue, regardless of the volume, area, and type of affected tissue. In the area of the joint capsule, vascular-nerve bundles, and serous cavities, the volume of necrectomy should be more restrained to avoid damaging them. Careful hemostasis is achieved by coagulating the vessels or suturing with ligatures, which must be removed after 2-3 days. The wound surface is treated with antiseptic solutions. The most effective sanitation of the ulcer defect is observed when using additional methods of wound treatment using a pulsating stream of antiseptic, vacuuming, ultrasonic cavitation, and treating the ulcer surface with a CO2 laser beam. The operation is completed by applying gauze pads soaked in a 1% solution of iodopyrone or povidone-iodine to the wound, which should preferably be placed over a mesh atraumatic wound dressing (Jelonet, Branolind, Inadine, Parapran, etc.), which, thanks to the properties of the indicated dressing materials, will allow the first dressing to be changed after the operation to be carried out virtually painlessly.

When the wound process passes into phase II, favorable conditions appear for using surgical methods of treatment aimed at the fastest closure of the ulcer defect. The choice of the surgical intervention method 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 the ulcer defect. These factors largely determine the treatment tactics. Trophic ulcers with an area of more than 50 cm2 have a weak tendency to spontaneous healing and are mostly subject to plastic closure. Localization of even a small ulcer on the supporting surface of the foot or functionally active areas of the joints makes surgical methods of treatment a priority. In case of arterial ulcer of the leg or foot, treatment is practically hopeless without preliminary vascular reconstruction. In some cases, treatment of skin ulcers is carried out only using conservative methods of treatment (ulcers in patients with blood diseases, systemic vasculitis, with a severe psychosomatic state of the patient, etc.).

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

• Treatment of trophic ulcers aimed at the pathogenetic mechanisms of ulcer formation, which include operations that reduce venous hypertension and eliminate pathological venovenous reflux (phlebectomy, subfascial ligation of perforating veins, etc.); revascularization operations (endarterectomy, various types of bypass, angioplasty, stenting, etc.); neurorrhaphy and other interventions on the central and peripheral nervous system; osteonecrectomy; tumor excision, etc.
• Treatment of trophic ulcers aimed directly at the ulcer itself (skin grafting):
  • autodermoplasty with or without excision of ulcers and scar tissue;
  • excision of the ulcer with closure of the defect using local tissue plastic surgery using acute dermotension or dosed tissue stretching; various types of Indian skin plastic surgery; island, sliding and mutually displaceable skin flaps;
  • ulcer plastic surgery using tissues from distant parts of the body on a temporary (Italian skin plastic surgery, Filatov stem plastic surgery) or permanent feeding stalk (transplantation of tissue complexes on microvascular anastomoses);
  • combined methods of skin plastic surgery.
• Combined operations combining pathogenetically directed
  • interventions and skin plastic surgery performed simultaneously or at different times
  • personal consistency.

In the foreign press devoted to the therapy of chronic wounds, for various reasons, the conservative direction of treatment dominates, which is apparently associated with the significant influence of companies producing dressings. It is logical to assume the need for a reasonable combination of conservative therapy and surgical treatment methods, the place and nature of which are determined individually, based on the patient's condition, the clinical course of the underlying disease and the ulcer 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, if possible, with closure of the defect by any of the known methods of skin grafting. Skin grafting should be used when a significant reduction in treatment time, improvement in the patient's quality of life, cosmetic and functional results are expected. In cases where plastic surgery of a wound defect is not indicated or impossible (small area of the defect capable of healing independently in a short time, 1 phase of the wound process, patient's refusal of surgery, severe somatic pathology, etc.), wounds are treated only by conservative methods. In this situation, conservative treatment, including adequately selected local treatment of trophic ulcers, plays one of the leading roles.