Venous Leg Ulcers (VLUs) are a common and challenging condition affecting the lower extremities¹. Highlighting the prevalence of this condition, VLUs currently account for 70-80% of ulcers evaluated and treated by various medical professionals, including primary care physicians, geriatricians, wound care specialists, phlebologists, surgical specialists, cardiologists, and vascular surgeons¹. In today’s blog post, we will delve into the nature of VLUs, their etiology, existing therapeutic approaches, and the potential benefits of hypochlorous acid (HOCl) in improving patient outcomes.

Disclaimer: This blog post is for educational purposes only and does not constitute medical advice. Please consult a healthcare professional for personalized medical guidance.

What is a Venous Leg Ulcer (VLU)?

A Venous Leg Ulcer (VLU) is a deep, full-thickness skin lesion typically localized near the ankle, resulting from impaired venous circulation in the lower extremities due to chronic venous disease (CVD)¹. This vascular insufficiency leads to increased venous pressure, microvascular damage, and subsequent skin breakdown¹⁻². VLUs represent a substantial clinical challenge, characterized by persistent pain, susceptibility to infections, and prolonged healing times, significantly compromising patients' quality of life¹⁻².

While VLUs can heal with standardized wound care and compression therapy, which are cornerstone treatment protocols, these ulcers present persistent management difficulties¹⁻². Compression therapy has demonstrated considerable effectiveness, achieving healing rates as high as 76% within a 16-week period according to existing studies¹. Nevertheless, the recurrence of VLUs remains a critical concern, with recurrence rates reported to be between 50% and 70% within six months post-initial healing¹. Addressing these recurrent ulcers remains a paramount objective in the comprehensive management of this often chronic and debilitating condition¹⁻².

What Causes Venous Leg Ulcers?

VLUs are primarily caused by chronic venous insufficiency (CVI), a condition where the veins in the legs do not function effectively. The pathophysiology involves several interconnected processes¹⁻²:

1. Valve Dysfunction: Venous valves, which prevent backflow of blood, become damaged or dysfunctional, leading to venous hypertension.
2. Venous Hypertension: Elevated pressure in the veins causes leakage of fluid and blood cells into the surrounding tissues.
3. Inflammation: The leaked substances provoke an inflammatory response, resulting in further tissue damage.
4. Capillary Damage: Sustained high pressure damages capillaries, reducing oxygen and nutrient supply to the tissues.
5. Skin Breakdown: Due to the compromised microcirculation and inflammatory milieu, the skin and subcutaneous tissues break down, leading to ulceration.

Other contributing factors include obesity, a sedentary lifestyle, deep vein thrombosis (DVT), and genetic predispositions¹. Advanced age and previous history of leg ulcers also increase the risk¹⁻².

Existing Treatments for Venous Leg Ulcers

The management of VLUs involves a multifaceted approach aimed at addressing the underlying venous insufficiency, promoting ulcer healing, and preventing recurrence. Current therapeutic modalities include¹⁻³:

1. Compression Therapy: The cornerstone of VLU management, compression therapy, helps reduce venous hypertension and improve blood flow. Compression bandages or stockings are commonly used.
2. Wound Care: Regular cleaning and dressing of the ulcer are essential to promote a moist healing environment and prevent infection.
3. Pharmacotherapy: Medications which improve blood flow and have anti-inflammatory or immunotherapy properties can be adjuncts in treatment.
4. Oxygen Therapies: Oxygen therapies, such as hyperbaric oxygen therapy (HBOT) or topical oxygen therapy, aim to enhance wound healing by increasing tissue oxygenation.
5. Negative wound pressure therapy (NWPT): Applies controlled negative pressure to the wound bed using a specialized dressing and vacuum pump system, accelerating the healing process with several mechanisms such as local edema reduction, reduction in bacteria, inflammatory mediators, and wound exudate.
6. Surgical Interventions: In severe cases, procedures such as saphenous vein ablation, vein stripping, or skin grafting may be considered.
7. Lifestyle Modifications: Weight management, increased physical activity, and leg elevation can support overall venous health.

Can Hypochlorous Acid Improve VLU Patient Outcomes?

Hypochlorous acid (HOCl) is emerging as a promising adjunct in the treatment of VLUs⁵. HOCl is a naturally occurring—and quite critical—substance in the human immune response, known for its potent antimicrobial and anti-inflammatory properties⁴⁻⁵. It can be synthesized and applied topically to enhance wound healing⁴. Here's how HOCl may improve VLU patient outcomes⁴⁻⁵:

1. Antimicrobial Action: HOCl effectively eradicates a broad spectrum of pathogens, including bacteria, viruses, and fungi, reducing the risk of infection in VLUs.
2. Anti-inflammatory Effects: By modulating the inflammatory response, HOCl can mitigate tissue damage and promote a conducive environment for healing.
3. Enhanced Healing: HOCl aids in the removal of necrotic tissue and biofilms, promoting granulation and epithelialization, which are critical for wound closure.
4. Safety Profile: HOCl is well-tolerated, with minimal cytotoxicity to human cells, making it a safe option for long-term use in chronic wounds.

Clinical Evidence Supporting HOCl in VLU Management

In a 2014 study⁴, researchers demonstrated the effectiveness of hypochlorous acid (HOCl) in treating venous leg ulcers (VLUs) through an overview of protocols implemented at Lake Wound Clinics from June 2006 to June 2014. Protocol included treatment regimens involving wound cleaning, autolytic debridement, and compression bandaging⁴. Instead of standard saline, aqueous solutions of HOCl were used for cleaning, debridement, packing, and dressing of VLUs, resulting in complete closure of all ulcers⁴. Comorbidities such as uncontrolled diabetes mellitus, advanced peripheral artery occlusive disease (PAD), smoking, steroid or street drug use, large initial ulcer size, and significant depth delayed healing⁴. In contrast, factors like advanced age, recurrent venous ulceration, stasis dermatitis, lipodermatosclerosis, morbid obesity, and infections with multidrug-resistant organisms did not significantly affect healing times⁴. This study suggests that incorporating HOCl solutions into VLU care protocols can mitigate the impact of certain comorbidities and expedite healing⁴.

Final Thoughts

Venous leg ulcers represent a debilitating and often chronic condition that can significantly impact a patient's quality of life¹⁻⁴. These ulcers necessitate an all-encompassing, multifaceted, and multidisciplinary treatment strategy to address the various aspects of the condition, from pain management to wound healing¹⁻⁴. Traditional therapies, such as compression therapy and wound dressings, continue to serve as the bedrock of treatment¹⁻⁴. However, the emergence of innovative solutions like hypochlorous acid has shown promising potential as adjunct therapies⁴⁻⁵. These can enhance the efficacy of conventional treatments and positively influence patient outcomes by promoting faster wound healing and reducing the risk of infection⁴⁻⁵. Despite the available treatment options, it remains paramount for patients and healthcare providers to engage in open discussions and collaboratively develop personalized treatment plans that best address the patient's unique needs and circumstances.