QUESTION FROM READER:LEG ULCERS

Q:Are there any new remedies for leg ulcers? My 75 year old father has suffered with them for 12 years. Tylex has been prescribed for the pain, but dosage has to be restricted because of his intake of beta blockers (Trasicor and nifedipine, plus occasional glyceryl trinitrate for angina). He follows a no salt diet, has regular exercise and elevates the leg. L S, Barking, Essex………

Leg ulcers are a common follow on from intermittent claudication (burning and cramp like leg pain), which results from restricted circulation brought on by hardening of the arteries. Although this condition can strike anyone, it is most common in the elderly, particularly men. Ulcers can also result from severe varicose veins.

One common medical treatment for persistent leg ulcers is to attempt a skin graft, rather than getting to the source of the problem.

Nutritionally, the best solution is vitamin E, which lowers the thickness of the blood, thereby improving circulation to the legs. Studies have found excellent success with intermittent claudication and leg ulcers. In one study, a patient with extensive leg ulceration was treated with 800 iu of vitamin E twice a day and vitamin E ointment rubbed over his entire body. His wounds healed completely within four months (The Summary, vol 26, December 1974).

Supplementing with folic acid and vitamin C can also help. In some cases, levels of the “bad” amino acid homocysteine may be abnormally high in patients with leg ulcers, contributing to hardening of the arteries. Folic acid has been shown to lower homocysteine levels and thereby prevent atherosclerosis (Nutr Rev, 1989; 47: 247-9).

Vitamin C helps restore leukocyte levels, often low in patients with leg ulcers. This helps to form collagen, the skin “glue” which aids healing and the formation of new tissue. In one study of 20 patients with pressure sores, the ulcers of those given 500 mg of ascorbic acid twice a day shrank by 84 per cent after one month, compared with only a 43 per cent reduction in the control group (The Lancet, 1974; ii: 544-6). As for minerals, zinc and selenium levels may be too low and copper levels too high in patients with leg ulcers (Acta Derm Venereol, Stockholm, 1986; 66: 237-40). In one study of patients with venous ulcers, one quarter had low blood zinc of some variety (Prezegl Dermatol, 1989; 76: 152-5).

Taking supplements of omega-6 fatty acids can also help reduce leg ulcers. In one study, patients given Efamol evening primrose oil enjoyed complete healing or great improvement in lower leg ulcers which had been there for years, often steadily getting worse (NZ Med J, 1986; 88: 552).

Besides the nutritional approach, there are many alternative treatments with proven success. The herb Centella asiatica (also known as Gotu kola) has active constituents which have been shown to increase collagen synthesis (Connect Tissue Res, 1990; 24: 107-20; Herbs Spices Med Plants, 1988; 3: 146-73). There’s also evidence that topical use of echinacea can promote wound healing (Med Klin, 1984; 79: 580-3).

Procyanidolic oligomers (PCOs) are the substances in red wine responsible for “the French paradox” (their low levels of heart disease despite a high fat diet), and are also present in flavonoids (usually extracted from grape skins). They have been shown to increase collagen production at standard dosages of 150-300 mg a day (Parfums Cosmet Arom, 1990; 95: 89-97).

To increase circulation to the legs, ginkgo biloba has shown repeated success in numerous clinical trials (Arzneim Forsch, 1992; 42: 428-36).

If your father has leg cramps as well, which are usually the result of a mineral imbalance, they can often be overcome with calcium and magnesium.

Homoeopathic preparations such as Lachesis, Lycopodium, Secale, Silicea, Carbo veg and Arsenicum alb (depending on your father’s constitutional type) are all useful (Townsend Letters for Doctors, July 1991).

Besides turning to alternative remedies, you can aid your father’s condition by altering his diet. In one case, an American naturopath got his patient to eliminate all refined carbohydrates, reduce salt, decrease fat and eliminate coffee, red meat, fried foods and dairy products. In addition to high doses (up to 10 g) of vitamin C (as calcium or magnesium ascorbate), folic acid, zinc and essential fatty acids, the patient was given echinacea and other naturopathic treatments for his heart. A mixture of Cabasil powder and calendula and cholorphyll oils was applied twice a day to the ulcer. The patient was told to take alternating cold and hot foot baths followed by castor oil packs for half an hour daily. After five months, the ulcer was entirely healed. He was told to stick to the regime indefinitely (Townsend, July 1991).

It may be worthwhile checking if the multiple drugs your father is taking are contributing to his condition. For instance, common side effects of the beta blocker nifedipine are muscle cramps and oedema of the extremities, which could help bring on the ulcers. Trasicor (oxprenolol hydrochloride), on the other hand, shouldn’t be given to your father. The Compendium of Data Sheets, the British drugs bible, says

it is specifically contra indicated in patients with severe peripheral circulatory disturbances, a category he undoubtedly falls into. He should also never be given ergot alkaloids with his beta blockers, since the drugs together cause peripheral blood flow to deteriorate. On its own, oxprenolol causes peripheral vascular disorders (usually coldness and paraesthesia (pins and needles) of the extremities a recipe for leg ulcers). As for glycerine trinitrate (which is nitroglycerine), the Compendium warns that it can amplify the blood pressure lowering effects of other drugs (ie, the beta blockers). This also would contribute to reduced blood flow of the extremities.

The US version of the Compendium, Physicians’ Desk Reference, says that nitroglycerine can lower cardiac output. So your father’s doctor is giving drugs to increase vasodilation, then adding a drug that slows the heart, probably contributing to reduced blood flow to the extremities.

You might wish to ask this doctor why your father needs to take two beta blockers, when combined heart drugs have never been shown to have any advantage over single drugs. You may also wish to investigate whether he can try non drug therapy for hypertension. A recent large scale study called “TONE” (Trial of Non pharmacologic Interventions in the Elderly) showed that reducing the intake of salt and losing weight is an effective and safe way to reduce hypertension in older people (JAMA,1998; 279: 839-46).