Venous Ulcer Assessment and Management: Using the Updated CEAP Classification System

Practice Points

Cathy Thomas Hess, BSN, RN, CWCN

ylastcolumn,Classification of Pressure Injuries, Although most leg ulcers are venous ulcers, the clini- discussed the importance of documenting the cian should suspect other causes when the wound looks details of pressure injuries using the updated atypical (presence of necrotic tissue, exposed tendon, M pressure injury classification system. This livedo reticularis on surrounding skin, or a deep, column discusses the updated classification system for “punched-out” ulcer), has been present for longer than venous ulcers, namely, the Clinical Etiology Anatomy 6 months, or has not responded to good care. Do not Pathophysiology (CEAP) classification system. To under- hesitate to take a biopsy when in doubt. stand the use of this classification, let’sbrieflydiscussthe Visual and palpable assessment may not be enough etiology, assessment, and management of venous ulcers. to determine the next steps. Objective testing may be needed to confirm the diagnosis, determine the etiology ETIOLOGY of the problem, and identify the anatomic site and sever- Venous ulcers are believed to account for approximately ity of disease pathway (Table). 70% to 90% of chronic leg ulcers.1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers.2 Table. CLINICAL FINDINGS ASSOCIATED WITH VENOUS In some studies, 50% of patients had venous ulcers that LEG ULCERS persisted for more than 9 months, and 20% had ulcers Wound location 30%–40% occur superior to the medial malleolus (near the that did not heal for more than 2 years. After healing, saphenous vein). The rest occur mainly in the lower third up to one-third of treated patients experience four or of the calf. more episodes of recurrence.1 The proper diagnosis and Appearance of Referred to as “ruddy” or “beefy red;” granular management of venous ulcers begin with a basic under- wound bed standing of the venous system of the lower extremities. Wound shape/ Flat, irregular wound margins without undermining margins ASSESSMENT Drainage/exudate May be moderate to heavy, depending on the amount of The diagnosis of venous ulceration depends on a thor- edema ough history and physical examination. In obtaining Surrounding skin Venous dilation, including submalleolar venous flare (typical the history,the clinician should focus on risk factors such of venous insufficiency), telangiectasias, reticular veins, as a history of deep vein thrombosis, leg trauma (crush varicose veins, edema (typical of more advanced venous injury, fracture, or surgery), congenital venous abnor- disease), atrophie blanche, maceration, hyperpigmentation mality,limited mobility with impaired calf muscle pump (from hemosiderin staining), and lipodermatosclerosis. Scarring from prior healed ulcers may be noted. (arthritis, paralysis, muscular disorders), pregnancies, con- gestive heart failure, family history of venous disease, Pain Controversial. Many believe that pain is usually not present, however several studies have reported severe pain obesity, and advanced age. Women are three times more occurring in as many as 76% of patients with venous ulcers. likely than men to have venous ulcers. Deep ulcers, particularly around the malleoli, or small Characteristic clinical findings are noted in the table venous ulcers surrounded by atrophie blanche are the most and include the presence of varicosities, hyperpigmenta- painful. Generally, patients report that pain occurs with leg tion, lipodermatosclerosis, and dermatitis. The shape of dependence (sitting, standing) and is reduced with leg the leg may also provide a clue, as the “inverted bottle elevation. ” shape is a sign of lipodermatosclerosis. Venous ulcers Reprinted with permission from Hess CT. Clinical Guide to Skin and Wound Care. 7th ed. tend to have flat wound edges, without undermining. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.

Cathy Thomas Hess, BSN, RN, CWCN, is Vice President and Chief Clinical Officer for Wound Care, Net Health 360 Professional Services. Ms Hess presides over Net Health 360 WoundExpert Professional Services, which offers products and solutions to optimize process and workflows. Address correspondence to Ms Hess via email: [email protected]. This article is considered expert opinion and was not subject to peer review.

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DIAGNOSIS AND MANAGEMENT • Apply compression when appropriate. Performing the appropriate diagnostic tests is paramount • Remove avascular tissue when appropriate. when evaluating the patient with a suspected venous • Manage infection: obtain culture and incorporate anti- ulcer. Testing identifies patients with venous pathology microbial dressings, if required. who may benefit from noninvasive or invasive treatments • Optimize nutrition: obtain a dietary consult. for vein-related symptoms, thereby decreasing the inci- • Protect the skin surrounding the ulcer. dence of recurrent ulceration. The results of the tests also • Control moisture with the appropriate dressing products. provide the basis for proper interventions and patient • Initiate wound measurements and outcomes: measure management. When assessing the patient with venous wound healing with the use of a validated digital wound disease, it is crucial to rule out coexisting peripheral arte- measurement and analysis tool and monitor outcomes. rial disease. • Provide patient education and continually assess patient/ Management of vascular ulcers has improved over the caregiver understanding of the treatment plan. past decade as clinicians have come to realize the impor- Although approximately 70% of venous ulcers heal tance of proactive measures and an interprofessional ap- within a 24-week period, 30% are unhealed after this proach. In addition, treatment modalities such as growth time.6 Data suggest that a venous leg ulcer that fails to factors and cellular- and tissue-based products can help decrease in size by 30% (percentage area reduction) of heal difficult wounds, accelerate the wound healing pro- its initial size over the first 4 weeks of treatment has a cess, and prevent new wound formation to a degree not 68% probability of failing to heal within 24 weeks.7 Using previously thought possible.3 Proper tests can detect re- the successive 4-week benchmark,5 providers should con- flux and/or obstruction and localize the anatomic site sider the following approaches: and severity of disease or identify coexisting peripheral • Reevaluate patient status with a complete patient artery disease. history, physical examination, and plan of care; review initial approaches. CEAP CLASSIFICATION • Monitor healing and outcomes; continue to use a vali- The American Venous Forum has developed a system dated digital wound measurement and analysis tool and for classifying venous disease using the acronym CEAP, monitor outcomes. which stands for Clinical signs, Etiology of venous disease • Sponsor granulation; consider alternative technologies (congenital or primarily or secondarily acquired), Ana- for wound management. tomic distribution (superficial, perforating, and/or deep • Introduce growth factors and/or cellular- and tissue-based veins), and Pathologic condition (obstruction and/or re- products. flux). It is an internationally accepted standard for de- • Revisit diagnosis; rule out differential diagnosis of lower scribing patients with chronic venous disorders based extremity ulcers. on clinical manifestations and the underlying venous • Provide patient education and reinforce adherence to pathology. Originally developed in 1993, the CEAP classi- the treatment plan. fication system was revised again this year. The changes The use of proper workflows coupled with noninva- in the 2020 version include the following: sive vascular testing facilitates identification of the ana- • adding corona phlebectatica as the C4c clinical subclass tomic and pathologic aspects of this system. Use of the • introducing the modifier “r” for recurrent varicose veins updated CEAP classification system provides a reliable and recurrent venous ulcers and reproducible classification of the many manifesta- • replacing numeric descriptions of the venous segments tions of chronic venous disease.• by their common abbreviations4 REFERENCES 1. Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health WORKFLOWS and the economy. Wound Repair Regen 2009;17(6):763-71. The key to treatment of any chronic wound is to address 2. Hellström A, Nilsson C, Nilsson A, Fagerström C. Leg ulcers in older people: a national study addressing the underlying problem. It is important to build your ini- variation in diagnosis, pain and sleep disturbance. BMC Geriatr 2016;16:25. 3. Agency for Healthcare Research and Quality. Skin substitutes for treating chronic wounds. January tial and follow-up assessment documentation and man- 2019. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/drafts-for-review/skin- agement workflows. Consider the following approaches substitutes_draft.pdf. Last accessed September 22, 2020. upon initial assessment when caring for a patient with 4. Lurie F, Passman M, Meisner M, et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg 2020;8(3):342-52. venous insufficiency:5 5. Hess CT. Clinical Guide to Skin and Wound Care. 7th ed. Philadelphia, PA: Lippincott Williams & • Prepare the wound bed to convert the molecular and Wilkins; 2013. cellular environment of a chronic wound to that of an 6. Parker CN, Finlayson KJ, Edwards HE. Predicting the likelihood of delayed venous leg ulcer healing and acute healing wound. recurrence: development and reliability testing of risk assessment tools. Wound Manage Prev 2017; • 63(10):16-33. Rule out arterial etiology, confirm venous etiology, and 7. Kantor J, Margolis DJ. A multicentre study of percentage change in venous leg ulcer area as a evaluate blood flow with the use of noninvasive tests. prognostic index of healing at 24 weeks. Br J Dermatol 2000;142(5):960-4.

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