How to manage ulcers in primary care

Ulcers are a condition commonly encountered in primary care. However, their management is often complex. Ulcers require a systematic approach to assessment and treatment. That's mostly because they can have various causes, ranging from arterial insufficiency to pressure or diabetic neuropathy. This article is a guide for healthcare providers to help diagnose, treat, and prevent ulcers in a primary care setting.

Types of ulcers

Ulcers can be broadly categorised into four types:

1. Venous ulcers are usually found on the lower legs, typically above the ankle. They are usually shallow and can have irregular edges. Patients often have a history of varicose veins or chronic venous insufficiency.
   
   
2. Arterial ulcers are often on the feet, particularly around pressure points. These ulcers are typically more painful, especially at night, and have a punched-out appearance. Peripheral arterial disease is often a comorbidity.
   
   
3. Diabetic (neuropathic) ulcers are commonly located on the feet, usually under pressure points like the metatarsal heads. Due to sensory neuropathy, they are usually painless but can quickly become infected.
   
   
4. Pressure ulcers occur on bony prominences due to prolonged pressure. They are common in patients with limited mobility or bed-bound patients.

The assessment

Proper ulcer assessment includes taking the patient's medical history, wound examination, vascular status check-up, and neuropathy assessment.

• Medical history should note any underlying chronic conditions, such as diabetes, cardiovascular disease, or previous history of ulcers.
  
  
• A wound examination is performed to document the size, depth, location, and condition of the ulcer. It also involves checking for any signs of infection, such as warmth, redness, or purulent drainage.
  
  
• Vascular status check-up assesses the blood flow to the area. Ankle-brachial index (ABI) is useful if arterial insufficiency is suspected.
  
  
• If the patient has diabetes, it is essential to check for peripheral neuropathy using tools like a monofilament.

Treatment plan

The treatment begins with cleaning the ulcer using saline solution (avoiding antiseptics that can delay wound healing). It is important to keep the ulcer moist using appropriate dressings. Foam dressings, hydrocolloids, or hydrogels can help, depending on the ulcer’s characteristics.

For venous ulcers, compression bandages or stockings are recommended unless contraindicated by arterial insufficiency.

Mechanical or autolytic debridement is often the best treatment option in primary care because regular removal of dead tissue promotes faster healing.

Additionally, for diabetic and pressure ulcers, the patient should use appropriate footwear or pressure-relieving devices to reduce ulcer recurrence.

Infection control

Systemic antibiotics are necessary if there are signs of infection, like redness, warmth, swelling, or drainage. Topical antibiotics are usually avoided to prevent resistance.

If the wound does not respond to standard antibiotic therapy, a wound culture may help identify the right treatment.

Addressing underlying conditions

Good blood glucose control is essential for diabetic patients. Patients with venous insufficiency may benefit from referral to vascular specialists. Also, smoking cessation, regular exercise, and dietary adjustments can support healing and prevent ulcer recurrence.

If the ulcer does not improve with primary care management, or if there are complications like severe infection or ischemia, a referral to a wound care specialist, podiatrist, or vascular surgeon is strongly recommended.

GPs play a crucial role in managing ulcers. They can prevent complications and reduce the need for specialist intervention. By identifying the type of ulcer, implementing wound care best practices, managing infections, and addressing comorbidities, clinicians can significantly improve patient outcomes. Additionally, patient education and preventive care are essential in reducing ulcer recurrence and enhancing long-term management.

– Dr Rosmy De Barros

For further information on this topic, you may be interested to learn more about the HealthCert online Professional Diploma program in General Dermatology.

See further articles, webinars, videos, podcasts, research, and more in primary care General Dermatology.

References

• Persoon, A., Heinen, M. M., Van Der Vleuten, C. J., De Rooij, M. J., Van De Kerkhof, P. C., & Van Achterberg, T. (2004). Leg ulcers: a review of their impact on daily life. Journal of Clinical Nursing, 13(3), 341-354.
• Millan, S. B., Gan, R., & Townsend, P. E. (2019). Venous ulcers: diagnosis and treatment. American family physician, 100(5), 298-305.
• Doughty, D. B. (2015). Arterial ulcers. Acute and Chronic Wounds-E-Book, 186.
• Jeffcoate, W. J., & Harding, K. G. (2003). Diabetic foot ulcers. The lancet, 361(9368), 1545-1551.
• Reddy, M., Gill, S. S., Kalkar, S. R., Wu, W., Anderson, P. J., & Rochon, P. A. (2008). Treatment of pressure ulcers: a systematic review. Jama, 300(22), 2647-2662.
• Steed, D. L. (2004). Debridement. The American journal of surgery, 187(5), S71-S74.