Venous Eczema – the prescriber’s role
Linda Nazarko MSc, PgDip, PgCert, BSc(Hons), RN, NIP, OBE, FRCN Consultant Nurse West London Mental Health Trust
Nurse Prescribing for Wound Care, ICO London 19 January 2016
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Aims and objectives To be aware of:
Pathophysiology of venous disease
Principles of diagnosis and treatment
Diagnosis & treatment of venous eczema
Diagnosis & treatment of infected venous eczema
The topical steroids in managing flare ups,
The role of emollient therapy
Compression in maintaining skin health and comfort
The value of the nurse practicing at advanced level.
Venous disease -pathophysiology
Elevated venous pressure stretches and damages valves
Valves fail, venous hypertension results Increased pressure superficial veins and
capillaries
Prevalence & pre-disposing factors
Venous disease affects 1/3 of adults. Predisposing factors: Abdominal tumour Ageing Obesity Pregnancy DVT
Ageing and the need for emollients Change Consequence Skin thins More easily damaged, increase risk of bruising
and skin tears
Replacement rate slows
Takes longer to heal
Reduced melanocytes
Burns more easily
Loss of collagen Saggy wrinkly skin Increased risk of skin tears, increased healing time, wounds more prone to breaking down
Loss of fat Prominent veins, increased risk of bruising Reduced protective layer, increased risk of skin damage, increased risk of pressure sores.
Loss of lipids and water
Dry skin, cracks easily Increased risk of infection
What is venous eczema?
“A non infective inflammatory condition that affects the skin of the lower legs” (Gawkrodger, 2006).
Clinical Etiological Anatomical Pathological (CEAP) classification
C0 No visible or palpable signs of venous disease
C1 Telangiectasies (spider veins) or reticular veins C2 Varicose veins, distinguished from reticular
veins by a diameter of 3mm or more. C3 Oedema C4 Changes in skin and subcutaneous tissue
secondary to chronic venous disease, divided into 2 sub-classes to better define the differing severity of venous disease:
C4a Pigmentation or eczema C4b Lipodermatosclerosis or atrophie blanche C5 Healed venous ulcer C6 Active venous ulcer
Principles of diagnosis and treatment
•This is a clinical diagnosisDiagnose venous eczema
•Assess and treat symptoms, e.g infection, weeping, scale, red inflammed skinTreat eczema
•Assess and check if safe to apply compression. If no contraindications apply compressionTreat swelling
•Obtain consent and refer for treatmentRefer for treatment of varicose veins
•Advise on weight management, standing, walking, elevation and leg crossing
Health promotion
•Treat any issues affecting quality of life that have not been addressed such as painQuality of life
Diagnosis of venous eczema
Clinical diagnosis, use CEAP classification, observe for stigmata of venous disease
Can lead to dry, thickened, scaly, cracked skin & can easily become infected
Diagnosis of infected venous eczema Check clinical
features venous disease
Check features of infection
Check bloods, FBC, CRP, U&E
Wound swab
Treatment of infected venous eczema
If systemic infection treat antibiotic therapy – local formulary usually flucloxacillin 500mg QDS if not penicillin allergic. Erythromycin or clindamycin if allergic.
Skin cleansing and debridment Potassium permanganate soaks weeping
eczema Topically steroids and emollients
Potassium permanganate
Astringent and antiseptic properties
One tablet in 4 litres water = 1:10,000 solution on average 4 tablets her bucket. Line the bucket. Soak 10-15 minutes
Use soft paraffin on nails to prevent staining
Use for 3-5 days once or twice daily
Store carefully ingestion can cause death through toxicity and organ failure
Infected venous eczema before & after ten days treatment
Treating red itchy inflamed skin -steroid therapy
Eczema is a chronic inflammatory skin condition. The skin becomes red, inflamed, itchy and scaly (Steen, 2007: Holden & Berth-Jones, 2004).
There are three stages of eczema: 1. Acute (when there is oozing, with tiny fluid filled
lesions and swelling) 2. Subacute (scaly and red) 3. Chronic (thick and hyperpigmented skin Steroids can be used in acute and subacute stages.
Use of steroid therapy Topical steroids
classified according to potency
All (other than mild) can be used daily
Use for 14 days early discontinuation = relapse
Don’t use long term – thins skin
Use emollient therapy afterwards
Tips for prescribing and administering steroids
The fingertip unit (FTU) is 0.5g of ointment and an adult lower leg requires three FTUs.
Use moderately potent and potent steroids
Apply steroids, leave to absorb and apply emollients 15-30 minutes after
Treating scale and lichenification
Remove hyperkeratotic skin using Debrisoft pad or UCS debridement cloth
Single treatment or 3-4 treatments
Why emollients are required
Asteotic element to venous eczema, skin is dry
Lipids restore normal barrier function and stop itching
Reduces infection risk and flare ups
CKS guidance on emollients Consideration Recommendation Dryness of skin Mild to moderately dry use creams
Moderate to severely dry – use ointments Weeping dermatitis Use creams as ointments will tend to slide off,
becoming unacceptably messy. Frequency of application
Creams are better tolerated but need to be applied more frequently and generously to have the same effect as a single application of ointment.
Choice and acceptability
Take account of the individual's preference, determined by the product's tolerability and convenience of use.
Efficacy and acceptance
Only a trial of treatment can determine if the individual finds a produce tolerable and convenient
One size does not fit all
More than one kind of product may be required. The intensity of treatment required and the area to be treated should guide treatment choice.
Balancing acceptability and effectiveness
The individual (and the prescriber) need to balance the effectiveness, tolerability and convenience of a product
Guide to emollients
Tips on emollient prescribing Be generous – an adult can require 500g of
emollient a week Tailor prescribing to patient preference and
ability to apply. Beware of emollients containing lanolin – can
cause sensitivity Consider emollients with urea if skin unbroken Be aware that patients can react to creams so
monitor effect and change if concerns
Refer for treatment
NICE guidance (2013) states that those with venous disease should be referred for assessment and treatment.
Treatments include endothermal ablation, endovenous laser treatment of the long saphenous vein ultrasound guided foam sclerotherapy and surgery.
Treat the swelling
Compression bandages if severe
Compression stockings when settled
Elevate feet – higher than hip
Elevate foot of bed
Benefits of compression
Reduces venous hypertension Reduces swelling Prevents ulceration Improves healing rates when
ulceration occurs Improves comfort
NICE recommendations on compression
‘Do not offer compression hosiery to treat varicose veins unless interventional treatment is unsuitable.’ But: Patient may decline or not be well enough for surgery.
Bandages or stockings – the evidence
Mobile patients with highly exuding ulcers may require three or four layer bandaging (NICE, 2015: SIGN, 2010)
In all other cases two layer compression stockings are as effective as four layer compression bandaging (Ashby et al, 2013)
Its important to consult the patient and ensure that compression method meets his or her needs and aspirations
Assessment prior to compression
Check for contraindications e.g severe heart failure
Doppler ultrasound to check compression will not lead to compromised circulation
Check condition of skin and debride if necessary
Hosiery selection
Consult the patient Thick, ribbed & sock like, for men and some
ladies Below knee Above knee Open and closed toe Get the colour right Grade two that is worn is better than grade
three that isn’t.
Health promotion
Promote health Weight loss if overweight Don’t stand around for long periods Activity - walking Don’t cross legs Don’t wear pop socks or socks that are
tight at the top
Maintaining healthy skin
Use emollients Protect skin from knocks Don’t smoke Protect skin from sun damage Maintain good nutrition Maintain hydration Maintain health
Quality of life
Venous disease can be horrible. The person may have dry itchy skin, weeping, infection, exudate, odour and swollen aching throbbing legs.
A structured approach to management and treatment should address these issues but check.
Address unresolved issues or refer
The value of advanced nursing practice
Enables and empowers person to experience best possible quality of life.
Treats problems promptly
Prevents complications Enriches the lives of
those we care for and our lives
Key points Venous disease is common in adults The prevalence of venous disease rises with
age Changes caused by venous disease can lead to
pain, discomfort and deteriorating health Lifestyle changes can improve well-being Effective management can treat complications
and improve comfort.
You can make a difference so use your diagnostic & prescribing skills.
Thank you for listening
Any questions?