Venous leg ulcer recurrence is common. Many patients will develop at least three or more leg ulcers during their lifetime, and sometimes will have an ulcer that never heals. They often experience alternating periods of healed ulceration and open ulcers.
This disease process is similar to that of long-term conditions such as multiple sclerosis or rheumatoid arthritis. Venous leg ulceration is therefore recognised as a long-term condition.
Treatment focuses on encouraging self-care and empowering patients to lead as normal a life as possible, while aiming to achieve a healed ulcer.
While healing may be realistic in many cases, if the underlying problem is not corrected surgically, the ulcer is likely to recur. This cycle of healing and recurrence may result in frustration for practitioners and feelings of hopelessness for patients.
Practitioners need to tell patients with venous leg ulceration that they have a long-term, recurring condition and that, while treatment may heal their ulcer, it is likely the ulcer will return at some point. Not understanding this could be a reason why many patients refuse to wear compression hosiery once their ulcer has healed.
Interventions to encourage self-care, such as the Expert Patient Programme, which helps patients manage conditions with minimal dependence on health professionals, may be appropriate. EPP has been introduced as a way of managing many long-term conditions such as rheumatoid arthritis, diabetes and asthma, and has had promising clinical outcomes.
For venous leg ulcer patients, a self-care programme could be developed that encourages them to perform activities to minimise recurrence, such as wearing compression hosiery, leg elevation, ankle exercises and moderate exercise such as walking. Furthermore, it could equip patients with the skills to adapt their lives to living with the constant uncertainty that their ulcer may recur at any time.
Currently, many leg ulcer services are paid according to set outcomes, such as the number of ulcers healed and how many weeks it took them to heal. They receive very little financial reward for follow-up appointments or providing “well leg” services. As a result, when an ulcer has healed, patients are discharged, only to return when another ulcer has developed.
Given that venous leg ulceration is a long-term, recurring condition, this seems at odds with the government emphasis on encouraging self-care. A recurrent ulcer may be preventable if patients are taught self-care activities thought to prevent recurrence.
Within tissue viability services, there is a saying: “A venous leg ulcer patient is a patient for life.” Unfortunately, it would appear that current provision does not reflect this. Health professionals need to ensure that commissioners of services are aware of the long-term nature of venous leg ulceration and emphasise the importance of encouraging self-care in this client group.
Annemarie Brown is an independent tissue viability consultant at Tissue Viability Solutions, Essex