It starts with a tingle, like a light breeze skimming the surface of the skin. But as inflammation and fluid build, the sensation grows, the skin tightens, and suddenly it feels ready to burst or, as many patients describe it, “bust open.”
In patients with unmanaged venous insufficiency, the skin truly does rupture and ulcerous wounds form, most commonly in the lower half of the leg. Such wounds tend to be wet, malodorous, itchy, painful and long-lasting, leading many patients to live debilitated, lonely lives at home.
But with simple self-monitoring of skin temperature and by using a cooling pack during temperature spikes, these patients can prevent wounds and take back control of their lives.
Teresa Kelechi, RN, Ph.D., a nurse researcher and associate dean for research and Ph.D. studies at the MUSC College of Nursing, has devoted her career to improving such patients’ quality of life and diminishing or ideally preventing their difficult symptoms.
“Venous disease is a prevalent and distressing condition,” she said. “And as researchers we often focus on understanding diseases, but we can sometimes neglect figuring out how to help people with their symptoms. I wanted to change that and offer people a way to remove the obstacles that keep them from living the life they want to have.”
Chronic venous insufficiency (CVI) resides on the more severe end of a spectrum of prevalent chronic venous diseases that also include varicose veins. These diseases are quite common and are estimated to affect 175 million individuals in the U.S.
With chronic venous diseases, the blood in the veins does not circulate properly back to the rest of the body. This can be caused by factors like poor valve function, obstructions and genetic variations, but the end result is that the pressure in the veins remains persistently high, especially in the lower limbs.
With more severe diseases like CVI, this can lead to fluid buildup, inflammation and wounds from broken skin. CVI is estimated to affect at least 2.5 million people in the U.S., and about 20% of these patients will develop venous leg ulcers.
Kelechi’s research grew out of her experiences as a clinician in a foot clinic where she saw many patients suffering from venous ulcers.
“In that clinic I saw many people with terrible balance problems who couldn’t walk, and they had severe foot problems as well as ulcers,” said Kelechi. “So I jumped in headfirst and studied inflammation, and how these particular types of ulcers, venous ulcers, developed due to poor circulation and inflammation.”
Teresa Kelechi, RN, Ph.D., uses symptom science to improve quality of life for patients with chronic venous insufficiency. Credit: Sarah Pack
During the course of Kelechi’s work, she kept returning to skin temperature as a harbinger of increased inflammation and wound development, and she spent years collecting and delving into the data, always with a core question in mind: can we prevent venous ulcers from developing?
While the skin remains intact, patients can lead fairly normal lives. But if the legs begin to swell and the skin turns red and flaky and bursts open, the resulting wound is very difficult to heal. Because of the poor venous circulation in the area, critical growth factors and other healing factors move into the region slowly, if at all, and healing can take weeks or months.
So prevention is ideal, and Kelechi and her colleagues found that increased temperatures in localized regions of the skin can serve as a warning sign for intervention. Specifically, an increase of 3-4°F over one or two days or a 24-hour dip and spike can indicate a skin area that is at risk for ulceration.
Phyllis Bonham, RN, Ph.D., a professor emerita of the MUSC College of Nursing, said that the temperature work was so convincing that measuring skin temperature is now included in clinical practice guidelines for assessing inflammation and infection in individuals with CVI and leg ulcers.
But the sophisticated measurements performed in a clinic during a research study or during sporadic visits aren’t available to people in their home, so Kelechi expanded her research to help people self-monitor their disease with the hope of preventing the complications that come with ulcerous wounds.
She began teaching patients to monitor their skin temperature at home with a simple handheld infrared thermometer wand, and with modern technologies, patients can now use small, convenient thermometers that they can plug into a smartphone. Patients take their own skin temperature on the vulnerable areas of their legs daily for 30 days to establish a baseline. Once they have their baseline, if they notice an increase in temperature for a day or two they start to treat the area with a cooling gel pack.
This simple intervention is performed as an addition to the standard of care for people with CVI, which includes compression via stockings or wraps, elevation and extra vigilance to avoid scratches, bumps or other injuries.
In Kelechi’s studies with patients, those who did not follow the monitoring and cooling process were more than twice as likely to develop ulcers as those who stuck with the procedure at least 85% of the time.
Moreover, the cooling process decreased many other symptoms, including pain, itching, tingling and cramping. Such symptoms may sound minor, but for patients regularly suffering from their effects, the improvements were life changing.
Patients who used to say, “My skin is always tingling – it’s driving me crazy, and I can't sleep,” were suddenly able to get some rest.
For Bonham, one of the notable successes of the cooling intervention for CVI is the decrease in itching.
“Itching as a symptom doesn’t get much respect in a clinical visit,” said Bonham. “But it is a miserable experience when it goes on and on, and it’s one of the key symptoms for individuals with venous disease. So the impact of cooling and other interventions is extremely important.”
Furthermore, when patients have the power to manage their own disease in simple ways, they can feel like they have their lives back. Patients who were formerly homebound can put on shoes again with reduced swelling, resume activities like work and social gatherings, and feel like a member of their family again.
Kelechi said, “I love seeing patients who can say to me, ‘That changed my life. I can go back to church, I don't have to hide my legs anymore, and I can spend time with my family.’”
Her work doesn’t end there. She is currently running a clinical study to look at loneliness and wound healing and the biomarkers that are common to both. It has already been shown that loneliness is correlated with worse healing outcomes for people with leg ulcers, and Kelechi wants to understand the inflammatory factors behind this phenomenon.
She’s also studying a wound powder and other treatment options for patients suffering from ulcers. The wound powder – made up of turmeric, sandalwood, mint and arnica – has proven promising in preliminary studies.
The patients always remain at the top of her mind. “I started this self-monitoring journey because I want people to have something they can do to help find that one little inch of improvement that can make all the difference.”
Progressnotes Winter 2023
