Ulcer and wound management guidelines

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Welcome to this Australian Prescriber Podcast. I'm Dr Justin Coleman, the publication's offshore GP correspondent, holed up in my bunker on the Tiwi Islands just north of Darwin.

Today, I'm speaking with Dr Stephen Yelland, who works by day as a humble GP on the Gold Coast but by night turns into a nationally renowned expert on the treatment of wounds and ulcers in primary care. He has helped write the new addition of Ulcer and Wound Management, the Therapeutic Guidelines book, and he also sits on the Wound Management Working Group of the MBS Taskforce.

Dr Stephen Yelland, welcome to the podcast.

Thank you, Justin. It's really great to be able to talk about such an important subject for primary care.

Let me start my first question with an anecdote. I was recently editing the forthcoming edition of Murtagh's Practice Tips, and I realised the leg ulcer section needed updating with the latest evidence-based treatments. Rather than turning to a vascular surgeon who looks at three ulcers before breakfast, a horrible image in itself, I turned to the person whom I genuinely think has the most to offer Australian GPs in common-sense ulcer management. That was you, Stephen Yelland. How did you develop your particular interest?

Very kind of you to say that, Justin. Many years ago as a humble GP in suburbia, I was faced with these ulcers that were coming in on many patients' lower legs in particular, and I got very frustrated by the fact that I just didn't really quite know how to manage them. My preparation as a medical student and as a resident at Royal Brisbane Hospital, I just was not prepared in any way to deal with such a chronic problem. As I've become more involved in wounds, I realise how major they are in Australian society and how most GPs, and most doctors actually, are just not prepared at all in any way to deal with them.

I think that's absolutely right, and I do think leg ulcers are the most important part of the new Therapeutic Guidelines edition to get right. Not only because, as you say, they're vital for patients and they're tricky to deal with, but also because plenty of free education sessions are run by nurses and specialists with direct connections to companies who make expensive wound products, yet these ulcers don't necessarily need the latest impregnated products that cost an arm and a leg, so to speak. I do like the simplicity of these guidelines. What are some of the key features of GPs managing chronic ulcers in primary care?

There's no doubt that the most important thing we must do as GPs is, when we look at a chronic wound, and a chronic wound by definition is a broken piece of skin that's been there for more than six weeks or so, we must know why is that broken skin there? What is it doing there? We need to understand the pathophysiology, the background, to how that wound got there. If we don't know that, then, as you referred to before, having all these products available, amazing products that can be thrown at us, the products do not heal the wound. It's the cause of the wound that's got to be corrected, and that's what makes the wound heal.

Particularly concentrating on the most common causes of these ulcers, I guess venous is right up there?

Yeah, well, up to 80% of the chronic wounds that we GPs see are the venous leg ulcers because of chronic venous insufficiency, chronic venous hypertension. If we don't treat that and manage that, we won't get that wound healed. There's lots of research that shows us GPs don't quite know what to do with the oedematous leg, how to get rid of that fluid. It's that fluid that's delaying the healing, we need to get rid of that.

Then, second to that would be, I guess, arterial ulcers, and then more unusual causes after that?

Yes. The mixed ulcers, of course. In Australian society, we have so much problem with diabetes and arterial disease, so we're going to have these mixed ulcers where we'll have venous problems and we'll have arterial problems. Then, of course, we then may just have the pure arterial wound, as well.

So, I guess it's crucial to be able to pick the symptoms and signs of a venous versus an arterial ulcer?

Yes, once you know it's a venous leg ulcer, and once you've actually ensured that there's adequate vascular supply, because that's really important to do that. We GPs, we're trained to do that, that's something we can do very, very well; we can feel pulses, we can look at the skin, we can look for signs of arterial disease, signs of chronic venous disease. Lots and lots of symptoms the patients can give us, as well, in their history.

When I actually assess a new patient, I can often make the diagnosis before I even look at the wound, because I've just taken a good history; asked about his medication, asked about cold feet, asked about oedema, asked about what their past history, have they had varicose veins before, have they had knee replacements, hip replacements. If the patient's also covered in skin cancers, well, you've also even got a better idea.

Most GPs these days know that compression is certainly important for venous ulcers, and yet it tends to be a bit tricky, a bit, sometimes, expensive. So, how do we go about compressing a leg which has a venous ulcer?

A lot of things come into why legs aren't compressed in general practice. Often it's lack of knowledge, lack of understanding, lack of skills. To apply the really clever, technical bandages you do need to be trained and have skills to be able to apply that. Then there's the cost factor and, of course, we GPs always say, "Oh, it's too expensive and we can't do this".

But there's a good program that we've set, a good way of actually going through the process of compression. It can be very cost-effective, and we're now aware that there's a three-layered tubular bandage system. It's a very good way for GPs to start off compression. It's cheap, we all have it in our treatment rooms. By putting three layers on, and if you look up the Guidelines exactly how to do that, you can see that this is a practical thing that can allow easy removal of these tubular bandages, allow us to dress the wound frequently if we need to change the wound dressing, say, two or three times a week, and we can reapply the tubular bandage.

Once we get the wound cleansed, debrided, clean and granulating, if we move the wound on through the phases of healing, that's when I aim to use some of these clever bandages, inelastic bandages, the stiff bandages, which can actually be applied and left for a whole week. Now, that's a very cost-effective way of managing compression. If you're treating a venous leg ulcer, not complicated by infection, not complicated by arterial disease, you should really expect healing anything up to 12 weeks. So you should be done and dusted and healed in 12 weeks, and that's our gold standard to be looking for.

When you say those three layers, just in case GPs get nervous that there's some fancy three layers we're talking about, I think you're talking about the same tubular bandage cut to three different lengths, rather than three different products.

That's right. Three different lengths applied. This was proven by an RCT study by Monash University proved this is a very effective method of applying quite significant sub-bandage pressures to squeeze all that oedema out of that lower limb.

Does it matter a lot what dressing you put over the actual ulcer itself?

This is a very good point because the dressing's actually there to deal with the properties of the wound bed. This is when people need to understand the acronym of TIME. You look at the whole patient, and you deal with their medications, you deal with their smoking, make your diagnosis, deal with the underlying problems. When you get down to the wound bed itself to say, "Well, how am I going to dress this wound before I put compression on?", go through your mind and say, "T-I-M-E".

T, what is the tissue in that wound? Is it viable tissue? Is it non-viable? Do I need to debride that? Get rid of all that revolting eschar, get rid of all that infected muck, clean that wound? There's various forms of debriding, and we GPs can access most of those forms.

I is for infection. Do I need to treat this wound because it's infected? The big, big issue is, try and avoid topical antibiotics and oral antibiotics as much as possible. Infection can be dealt with by really good cleansing, really good debriding, and the use of antiseptic products. There's fantastic antiseptic products that are out there.

M is for moisture, and this is where a lot of the dressings, the technological advances of the dressings, have come around dealing with managing the fluid that's coming out of a wound.

E is looking at the edge of the wound and the periwound. The periwound, of course, is all that area around the wound. It may be very eczematous. For example, you can imagine a venous leg ulcer where people have got the stasis dermatitis, a lot of scaly, inflamed skin, and that may need to be treated with a cortisone ointment, for example, or a zinc bandage or whatever, to treat that periwound.

Stephen Yelland, talking of time, it's probably time we moved on and let readers look up any further details in their Therapeutic Guidelines.

One of the things I love about Therapeutic Guidelines is that it spends time getting some of the little stuff right; the small skin traumas that are so common in general practice but probably never make it into the hospital or, indeed, take up much space in surgical textbooks. I'm thinking of small burns, scrapes and bruises.

Let's have a look at minor burns, something we see very often in general practice. What's a basic approach to a minor burn management these days?

Certainly you need to understand your rule of nines and how to assess the surface area of the burn. People get confused. All these products are available for managing minor burn, the sort of burns we should be, in primary practice, looking after ourselves. The ones that are basic, just superficial in depth, fairly painful and quite moist, but a good capillary return. If you are dealing with full-thickness burn, well you really have to consider, "Should I be referring that one on?". The criteria for the referral of a burn to a specialist centre is detailed in the Guidelines, of course.

Electrical burns and chemical burns, we have to be very careful, but if we're just dealing with a scald, cooling the skin's important, and then watching for infection, dealing with any blisters that might occur. Do we deroof them or just leave them alone, and what dressings might be appropriate?

For a little while silver sulfadiazine cream, which I was taught to use in my day, has not been recommended. Instead, we're looking at silver dressings for contaminated or infected burns. Is that right?

It's not something we recommend these days. It leaves an eschar in the wound, if that green eschar is there that's got to be washed away, which really affects the assessment of the wound bed. You've got to keep watching this wound bed, because the wound may not show itself for two or three days later, so you've got to be careful not to cover that up by covering it in one of these silver creams.

But these new dressings that are available are wonderful and certainly can help prevent infection. They individually are expensive. There's foam dressings that can have silver impregnated in them, and there's products like Acticoat and what have you that are very, very powerful silver dressings. They're used extensively in burns units throughout Australia.

Thank you. We'll move on to abrasions. Again, a common thing. Someone falls off their bike or knocks off a bit of skin. Sometimes a bit of dirt and fibres in the wound. Debridement is important and watching for infection, but also similar dressings to burns. Is that right?

Yes, a lot of those dressings I've already mentioned would be fine in this situation. Certainly, you want to clean those wounds well and get any debris out of them; you don't want any tattooing occurring. Moist wound healing, of course, is the answer to all our wound problems. Keeping a wound just the right moisture can certainly promote healing and epithelialisation. We don't any scabs, we don't want any scars forming on wounds. So, good cleaning, applying a moist-wound dressing, would certainly give you a good result and a good cosmetic result as well.

I also notice in that section a little tip I was unaware of, that if someone has a hematoma which you decide is worth incising, and not all need to be, of course, they suggest incising at the periphery of the hematoma rather than the skin in the middle of it. I'll just leave that with you, because I've always just poked a hole in the top, but going towards the side is apparently recommended.

Let's move on now to high-risk feet, and in the Therapeutic Guidelines there's a fair bit of new information there.

Well, Justin, I think as primary care providers, we need to take responsibility for solving a major, major problem. Australia has got one of the worst amputation rates in the world for people suffering from diabetes. If you have an amputation, you have a 50% chance of dying within five years. The mortality is worse than breast cancer, prostate cancer, lymphoma. We need to appreciate that this is really scary.

Who is the best people in Australia to do something more for our patients suffering from diabetes? We GPs. We are the gatekeepers to the system. We can assess feet, we can look at all our diabetic patients and say, "Right. Because of various criteria based around uropathy, vascular disease, skin integrity and comorbidities, we can put these people into a low-, mid- or high-risk group. We have got the systems of the chronic disease management in Australia well paid, used properly, we can use our nurses to do that, and advise patients what they need to do to prevent wounds; by looking after their feet in terms of footwear, emollients, nutrition, and just your general wellbeing.

Thank you, Stephen. My favourite part of learning in general practice is focusing in on the grey areas, because that's where the evidence is most likely to change. So, major wounds are sometimes actually easier on the brain because GPs quickly recognise that we need to throw everything at them including referral to someone good at handling sharp objects.

But let's look at the borderline things, those lesions where we're left wondering, "Should I use antibiotics?", or, indeed, "Should I take a swab to tell me whether I should use antibiotics?". How is the role of swabbing and antibiotics slowly changing with new evidence?

This is a really important area, not just for wounds but for the community. What's that best way to deal with infection? When it comes to wounds, the best way to diagnose infection is the clinic signs. Swabbing is only just there to guide us if we particularly need to go look for a particular germ. Most of the time, we should be able to make our diagnosis of infection based on the clinical signs. We need to look at a wound to see whether it's just contaminated, because all wounds are contaminated and, if we swab wounds willy-nilly, we're costing the system a lot of money and we'll grow bacteria, which are just the contaminated bacteria. Because the bacteria that actually create problems with the wound and delay healing are the bacteria lying underneath the wound bed, and this is a really important concept for everyone to understand. Never swab the puss and muck that's sitting on the top. That's useless, that's just contaminated material. Clean that off. If you do want to take a swab, you do the Levine technique; you push firmly on the clean area of the wound bed, and you try and get that exudate out from underneath the wound bed.

Otherwise, the other way to go looking for bacteria is actually using a biopsy and taking some of the tissue. If you take a biopsy, you actually may be killing two birds with one stone here, because the two main reasons why wounds don't heal is: one, you got the diagnosis wrong, and two, there's some underlying infection delaying the situation. Take two separate biopsies or take one piece and cut it in two, and ask for histopathology and ask for microbiology.

What sort of signs are we looking at that should make us use an antibiotic on an ulcer?

First of all, topical antibiotics almost have no role to play whatsoever in wound management, and that's both acute and chronic. Oral antibiotics should only be used when the wound itself is heading into the area of spreading infection: that you've got increased size of the wound; you have new breakdown ulceration occurring around the wound; there may be increased smell, increased exudate, and the patient themselves may be systemically unwell. But prior to that stage, good cleaning, good debriding, and smart of use of the antiseptic, not antibiotic but antiseptic, dressings will get you through, reverse that wound, and get you back on track.

Stephen Yelland, the thing I love about talking to you is that you drop dozens of pearls into your conversation and you keep it all very simple. I think it's been a delight talking to you, and I encourage listeners to look up the latest ulcer and wound guidelines from Therapeutic Guidelines.

Stephen, thank you very much for chatting to us today.

Justin, it's been a pleasure.

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My guests’ views are their own and don't represent Australian Prescriber, and my views are certainly all mine.