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

,

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?