Factors that influence healing of chronic venous leg ulcers: a retrospective cohort

Scotton, Marilia Formentini; Miot, Hélio Amante; Abbade, Luciana Patricia Fernandes

doi:10.1590/abd1806-4841.20142687

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Investigation • An. bras. dermatol. 89 (3) • May-Jun 2014 • https://doi.org/10.1590/abd1806-4841.20142687 copy

Factors that influence healing of chronic venous leg ulcers: a retrospective cohort^* * Work performed at the Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu - Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP) - Botucatu (SP), Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

BACKGROUND:

Venous ulcers have a significant impact on patient quality of life, and constitute a worldwide public health problem. Treatment is complex, with high failure rates.

OBJECTIVES:

To identify clinical and therapeutic factors that influence healing of venous ulcers.

METHODS:

Retrospective cohort study of patients with venous ulcers. Ulcer area was measured at the first visit (T0) and after 6 months (T6) and 1 year (T12). A reduction in ulcer area of 50% or more at T6 and T12 was the outcome of interest, weighted by clinical, demographic and treatment aspects.

RESULTS:

Ninety-four patients were included (137 ulcers). A reduction in ulcer area of 50% or more was seen in 40.1% of patients (95%CI 31.9 to 48.4%) at T6 and 49.6% (95%CI 41.2 to 58.1%) at T12. Complete healing occurred in 16.8% (95%CI 10.5 to 23.1%) at T6 and 27% (95%CI 19.5 to 39.5%) at T12. The lowest ulcer area reductions at T6 were associated with longstanding ulcer (RR=0.95; 95%CI 0.91 to 0.98), poor adherence to compression therapy (RR=4.04; 95%CI 1.31 to 12.41), and infection episodes (RR= 0.42; 95%CI 0.23 to 0.76). At T12, lower reductions were associated with longstanding ulcer (RR=0.95; 95%CI 0.92 to 0.98), longer topical antibiotic use (RR=0.93; 95%CI 0.87 to 0.99), and systemic antibiotic use (RR=0.63; 95%CI 0.40 to 0.99).

CONCLUSIONS:

Longstanding ulcer, infection, poor adherence to compression therapy, and longer topical and systemic antibiotic use were independently correlated with worse healing rates.

Cohort studies; Leg ulcer; Lower extremity; Risk factors; Varicose ulcer; Wound healing

Variable		Value
		N	%
Sex
	Female	67	71.3
	Male	27	28.7
Age (years) - median (IQR)		60.5	52.1-70.2
Number of visits - mean (SD)		5.9	2.0
Duration of open ulcer (years) - median (IQR)		4.0	2.6-8.1
Ulcer area at baseline (cm2) - median (IQR)		11.4	4.0-38.4

Number of ulcers per patient
	One	58	61.7
	Two	29	30.9
	More than two	7	7.4

Affected leg
	Right	62	45.3
	Left	75	54.8

Location on leg
	Medial	48	35.6
	Lateral	34	25.2
	Anterior	24	17.8
	Posterior	9	6.7
	More than one location	20	14.8

Critical colonization during the first year of follow-up		48	35

Infection during the first year of follow-up		35	25.5

Etiology
	Primary varicose veins	119	86.9
	Post-thrombotic syndrome	18	13.1

Comorbidities
	Hypertension	66	48.2
	Diabetes mellitus	31	22.6
	Heart failure	1	2.7
	Smoking	14	14.3

Compression therapy
	Elastic stocking	31	22.6
	Elastic bandage	99	72.3
	Unna boot	54	39.4

Type of dressing
	Debriding	79	57.6
	Topical antibiotic	39	28.4
	Occlusive (hydrogel, activated charcoal with silver, hydrocolloid, hydrofiber)	82	59.8

Systemic antibiotic therapy
	Therapeutic	36	26.3
	Prophylactic	6 (4.4)

		Bivariate analysis			Multivariate analysis
Variable	>50% area reduction at T6 (N=55)	No >50% area reduction at T6 (N=82)	Relative risk (95%CI)	p-value	Relative risk (95%CI)	p-value
Female sex^a a Qualitative variable expressed as N (%);	34 (62)	62 (76)	0.70 (0.47-1.06)	0.09

Patient age,^b b Quantitative variable expressed as median and interquartile range (IQR) in years	58 (50-69)	61 (52-72)	0.99 (0.98-1.00)	0.14

Duration of active ulcer,^b b Quantitative variable expressed as median and interquartile range (IQR) in years	3 (2-7)	5 (2-17)	0.97 (0.93-1.00)	0.09	0.95 (0.91-0.98)	0.01

Ulcer location^a a Qualitative variable expressed as N (%);				0.55
Medial	25 (46)	23 (28)	1.76 (0.92-3.37)
Lateral	12 (22)	22 (27)	1.43 (0.69-2.98)
Anterior	8 (15)	16 (20)	1.42 (0.65-3.12)
Other / More than one	10 (18)	21 (26)	1.00 (-)

Area at baseline,^b b Quantitative variable expressed as median and interquartile range (IQR) in cm²	7 (4-25)	20 (4-87)	1.00 (0.99-1.00)	0.21	1.00 (0.99-1.00)	0.16

Critical colonization^a a Qualitative variable expressed as N (%);	15 (27)	33 (40)	0.69 (0.42-1.15)	0.15

Infection^a a Qualitative variable expressed as N (%);	8 (15)	27 (33)	0.47 (0.24-0.92)	0.03	0.42 (0.23-0.76)	0.01

Post-thrombotic etiology^a a Qualitative variable expressed as N (%);	9 (16)	9 (11)	1.10 (0.61-1.97)	0.76

Hypertension^a a Qualitative variable expressed as N (%);	24 (44)	42 (51)	0.80 (0.52-1.23)	0.32

Diabetes mellitus^a a Qualitative variable expressed as N (%);	24 (44)	42 (51)	0.80 (0.52-1.23)	0.32

Compliance with rest^a a Qualitative variable expressed as N (%);	39 (71)	49 (60)	1.21 (0.76-1.91)	0.42

Compliance with occlusive dressings^a a Qualitative variable expressed as N (%);	46 (84)	76 (93)	0.68 (0.42-1.09)	0.11	1.18 (0.42-3.30)	0.75

Compliance with compression therapy^a a Qualitative variable expressed as N (%);	39 (71)	47 (57)	1.25 (0.79-1.98)	0.34	4.04 (1.31-12.41)	0.02

Duration of debriding dressing use,^b b Quantitative variable expressed as median and interquartile range (IQR) in months	1 (0-4)	2 (0-9)	0.97 (0.92-1.01)	0.13

Duration of topical antibiotic use,^b b Quantitative variable expressed as median and interquartile range (IQR) in months	0 (0-0)	0 (0-2)	1.02 (0.97-1.07)	0.49

Therapeutic use of systemic antibiotics^a a Qualitative variable expressed as N (%);	9 (16)	28 (34)	0.33 (0.15-0.76)	0.01

		Bivariate analysis		Multivariate analysis
Variable	>50% area reduction at T12 (N=68)	No >50% area reduction at T12 (N=69)	Relative risk (95%CI)	p-value	Relative risk (95%CI)	p-value
Female sex^a a Qualitative variable expressed as N (%);	47 (69)	49 (71)	0.96 (0.67-1.38)	0.83

Patient age,^b b Quantitative variable expressed as median and interquartile range (IQR) in years	60 (49-73)	60 (52-69)	1.00 (0.99-1.00)	0.91

Duration of active ulcer,^b b Quantitative variable expressed as median and interquartile range (IQR) in years	3 (1-6)	6 (3-18)	0.95 (0.92-0.99)	0.01	0.95 (0.92-0.98)	0.02

Ulcer location^a a Qualitative variable expressed as N (%);				0.74
Medial	25 (37)	27 (33)	1.28 (0.75-2.19)
Lateral	19 (28)	15 (22)	1.51 (0.87-2.61)
Anterior	11 (16)	13 (19)	1.42 (0.78-2.58)
Other / More than one	13 (19)	18 (26)	1.00 (-)

Area at baseline,^b b Quantitative variable expressed as median and interquartile range (IQR) in cm²	10 (4-38)	13 (5-82)	0.99 (0.99-1.00)	0.18

Critical colonization^a a Qualitative variable expressed as N (%);	19 (28)	29 (42)	0.76 (0.51-1.15)	0.19

Infection^a a Qualitative variable expressed as N (%);	14 (21)	21 (30)	0.63 (0.38-1.04)	0.07

Post-thrombotic etiology^a a Qualitative variable expressed as N (%);	10 (15)	8 (12)	1.02 (0.61-0.69)	0.95

Hypertension^a a Qualitative variable expressed as N (%);	29 (43)	37 (54)	0.82 (0.58-1.17)	0.28

Diabetes mellitus^a a Qualitative variable expressed as N (%);	12 (18)	19 (28)	0.81 (0.51-1.28)	0.36

Compliance with rest^a a Qualitative variable expressed as N (%);	45 (66)	43 (62)	1.08 (0.75-1.56)	0.68

Compliance with occlusive dressings^a a Qualitative variable expressed as N (%);	61 (90)	61 (88)	1.15 (0.65-2.03)	0.64

Compliance with compression therapy^a a Qualitative variable expressed as N (%);	43 (63)	43 (62)	0.97 (0.68-1.39)	0.88

Duration of debriding dressing use,^b b Quantitative variable expressed as median and interquartile range (IQR) in months	1 (0-4)	2 (0-9)	0.97 (0.92-1.01)	0.13

Duration of topical antibiotic use,^b b Quantitative variable expressed as median and interquartile range (IQR) in months	0 (0-0)	0 (0-3)	0.95 (0.89-1.02)	0.15	0.93 (0.87-0.99)	0.05

Therapeutic use of systemic antibiotics^a a Qualitative variable expressed as N (%);	14 (21)	23 (33)	0.66 (0.40-1.09)	0.10	0.63 (0.40-0.99)	0.05

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E-mail: revista@sbd.org.br

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[1] MAILING ADDRESS: Luciana Patricia Fernandes Abbade, Distrito de Rubião Jr, S/N, 18610-340 Botucatu, SP. E-mail: lfabbade@fmb.unesp.br

	I)				Identification:
Patient Name:					ID: Date of Birth: ___/___/___
					Date of First Visit: ___/___/___
				II)	Ulcer Characteristics:

					ULCER 1	ULCER 2	ULCER 3	ULCER 4	ULCER 5
DURATION
LOCATION
REGION OF LIMB
CRITICAL COLONIZATION
INFECTION
CAUSE


	Ulcer Area
	Area at First Visit (T0):
	Area at 6-Month Follow-Up (T6):
	Area at 12-Month Follow-Up (T12):

	III)	Comorbidities:
	1) HTN ( )	2) DM ( )	3) CHF ( )	4) Smoking ( )

	IV)	Treatment:
	1)	Number of visits at the outpatient ulcer clinic:
	2)	Type of compression therapy:
		- Elastic stocking ( )
		- Elastic bandage ( )
		- Unna boot ( )
		- Other ( ) Please specify _____________________

	III)	Comorbidities:
	1) HTN ( )	2) DM ( )	3) CHF ( )	4) Smoking ( )

	IV)	Treatment:
	1)	Number of visits at the outpatient ulcer clinic:
	2)	Type of compression therapy:
		Elastic stocking ( )
		- Elastic bandage ( )
		- Unna boot ( )
		- Other ( ) Please specify _____________________

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Factors that influence healing of chronic venous leg ulcers: a retrospective cohort* * Work performed at the Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu - Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP) - Botucatu (SP), Brazil.

BACKGROUND:

OBJECTIVES:

METHODS:

RESULTS:

CONCLUSIONS:

Factors that influence healing of chronic venous leg ulcers: a retrospective cohort^* * Work performed at the Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu - Universidade Estadual Paulista "Júlio de Mesquita Filho" (UNESP) - Botucatu (SP), Brazil.