How should I manage a patient with a venous ulcer who is not responding to compression therapy?

For a patient with a venous ulcer not responding to compression therapy, referral to a vascular service is essential for comprehensive assessment including duplex ultrasound to confirm venous insufficiency and plan further treatment NICE CG168. Optimising wound care is critical, including regular debridement by trained professionals and appropriate dressings to manage exudate and prevent infection Pugliese 2016. Infection should be actively assessed and treated as it can impede healing Pugliese 2016. If compression therapy alone is insufficient, consider interventional treatments such as endothermal ablation, ultrasound-guided foam sclerotherapy, or surgery to correct underlying venous reflux NICE CG168. Adjunctive therapies like negative pressure wound therapy may be considered post-debridement to promote healing, although evidence is stronger in diabetic foot ulcers and may be extrapolated cautiously Pugliese 2016. Emerging treatments such as electroceutical devices have shown promise in improving healing rates in non-healing venous leg ulcers, potentially offering cost-effective adjuncts to standard care Guest et al. 2018. Throughout management, patient education on leg elevation, weight management, and physical activity should be reinforced to support venous return and ulcer healing NICE CG168. Multidisciplinary involvement is key to address comorbidities and optimise overall care NICE CG168.