Clean the base of the ulcer with saline or cleansers, such as Saf-Clens®. A curette or small scissors can be used to remove the yellow fibrin eschar; local anesthesia may be used if the areas are very tender.
Overall, there is little evidence to support topical antibiotics other than cadexomer iodine for the treatment of venous insufficiency ulcerations. Metronidazole gel is used to reduce bacterial growth and odor. Red dermatitic skin is treated with a medium- to high-potency corticosteroid ointment such as triamcinolone acetonide 0.1% ointment. The ulcer is then covered with an occlusive hydroactive dressing (DuoDerm® or Cutinova®) or a polyurethane foam (Allevyn) followed by an Unna zinc paste boot. This is changed weekly. The ulcer should begin to heal within weeks, and healing should be complete within 4–6 months. If the patient has no history of skin cancer in the area, becaplermin (Regranex) may be applied to ulcers that are not becoming smaller or developing a granulating base. Some ulcerations require grafting. Full- or split-thickness grafts often do not take, and pinch grafts (small shaves of skin laid onto the bed) may be effective. Cultured epidermal cell grafts may accelerate wound healing, but they are very expensive. They should be considered in refractory ulcers, especially those that have not healed after a year or more of conservative therapy.
No topical intervention has evidence to suggest that it will improve healing of arterial leg ulcers.
Pentoxifylline, 400 mg orally three times daily administered with compression dressings, is beneficial in accelerating healing of venous insufficiency leg ulcers. Zinc supplementation is occasionally beneficial in patients with low serum zinc levels.
In the absence of cellulitis, there is no role for systemic antibiotics in the treatment of venous insufficiency ulcers. The diagnosis of cellulitis in the setting of a venous insufficiency ulcer can be very difficult. Surface cultures are of limited value. The diagnosis of cellulitis should be considered in the following settings: (1) expanding warmth and erythema surrounding the ulceration, with or without (2) increasing pain of the ulceration. The patient may also report increased exudate from the ulceration, but this without the other cardinal findings of cellulitis does not confirm the diagnosis of cellulitis. If cellulitis accompanies the ulcer, oral antibiotics are recommended: dicloxacillin, 250 mg four times a day, or levofloxacin, 500 mg once daily for 1–2 weeks, is usually adequate. Routine use of antibiotics and treating bacteria isolated from a chronic ulcer without clinical evidence of infection is discouraged. If the ulcer fails to heal or there is a persistent draining tract in the ulcer, an underlying osteomyelitis should be sought.