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Healthnotes

Skin Ulcers

Also indexed as: Bedsores, Decubitus Ulcer, Leg Ulcer, Pressure Ulcer, Venous Ulcer

Soothe and heal the sores on your skin for more comfort and fewer infections. According to research or other evidence, the following self-care steps may help you prevent or treat skin ulcers:

Seek support from C
Take 1,000 mg of vitamin C every day to speed healing

Go for the protein
Help prevent and heal skin ulcers by eating a diet high in protein and adequate in calories

Think zinc
Under the supervision of a doctor, take at least 50 mg of a zinc supplement, plus 1 to 3 mg of copper, each day to facilitate tissue growth

Try on natural topicals
Use ointments containing zinc, aloe, or gotu kola extract to help heal skin ulcers

Get a checkup
Visit your healthcare provider to find out if your skin ulcers are caused by a treatable medical condition

These recommendations are not comprehensive and are not intended to replace the advice of your doctor or pharmacist. Continue reading the full skin ulcers article for more in-depth, fully-referenced information on medicines, vitamins, herbs, and dietary and lifestyle changes that may be helpful.

About skin ulcers

Skin ulcers are open sores that are often accompanied by the sloughing-off of inflamed tissue.

Skin ulcers can be caused by a variety of events, such as trauma, exposure to heat or cold, problems with blood circulation, or irritation from exposure to corrosive material. Pressure ulcers, also known as decubitus ulcers or bedsores, are skin ulcers that develop on areas of the body where the blood supply has been reduced because of prolonged pressure; these may occur in people confined to bed or a chair, or in those who must wear a hard brace or plaster cast. Skin ulcers may become infected, with serious health consequences. Other health conditions that can cause skin ulcers include mouth ulcers (canker sores), chronic venous insufficiency, diabetes, infection, and peripheral vascular disease.

Product ratings for skin ulcers

Science Ratings

Nutritional Supplements

Herbs

Essential fatty acids (topical, for prevention of pressure ulcers)

Evening primrose oil

Flavonoids (hydroxyethylrutosides)

Flavonoids (diosmin, hesperidin)

Folic acid

Hyaluronic acid

Vitamin C

Vitamin E (oral)

Zinc (oral and topical)

Aloe

Gotu kola (topical and by intramuscular injection)

Vitamin E (topical)

Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars

Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star

For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support and/or minimal health benefit.

What are the symptoms?

People with a skin ulcer may have an area of reddened skin. In advanced cases, people may have areas where the skin is open and oozing fluid.

Dietary changes that may be helpful

Dietary deficiencies may hinder the body’s ability to heal pressure ulcers. A controlled study of 28 malnourished nursing home patients with skin ulcers found that ulcer healing was significantly enhanced by a high-protein diet (24% protein) compared with a lower protein (14%) diet.¹ A controlled study of critically ill older patients found that increasing calorie and protein intake with dietary supplements for 15 days reduced the risk of developing a skin ulcer.²

Other therapies

Healthcare providers recommend shifting position at least every two hours to avoid sustained pressure on the same area of the body. Some people might benefit from special mattresses or supports. For skin ulcers in general, wound dressings need to be changed frequently. Severe cases might require surgery to remove diseased tissue and to repair the wound.

Vitamins that may be helpful

Antioxidants such as vitamin C, vitamin E, and glutathione are depleted in healing skin tissue.³ One animal study found that vitamin E (alpha-tocopherol) applied to the skin shortened the healing time of skin ulcers.⁴ Another animal study reported that administration of oral vitamin E before skin lesions were introduced into the skin prevented some of the tissue damage associated with the development of pressure ulcers.⁵ A controlled human trial found that 400 IU of vitamin E daily improved the results of skin graft surgery for chronic venous ulcers.⁶ No further research has investigated the potential benefit of vitamin E for skin ulcers.

Animal research has suggested that vitamin C may help prevent skin ulcers,⁷ and in a preliminary study,⁸ elderly patients with pressure ulcers had lower blood levels of vitamin C than did ulcer-free patients. Supplementation with vitamin C (3 grams per day) increased the speed of healing of leg ulcers in patients with a blood disorder called thalassemia, according to a double-blind study.⁹ And while a double-blind trial of surgical patients with pressure ulcers found that supplementation with 500 mg of vitamin C twice a day accelerated ulcer healing,¹⁰ a similar double-blind trial found no difference in the effectiveness of either 20 mg per day or 1,000 mg per day of vitamin C.¹¹

An older preliminary report suggested that large amounts of folic acid given both orally and by injection could promote healing of chronic skin ulcers due to poor circulation.¹² No controlled research has further investigated this claim.

A controlled trial found that topical application of a hyaluronic acid compound with compression bandaging was significantly better than bandaging alone for healing chronic venous skin ulcers.¹³ No research has investigated whether oral hyaluronic acid supplements might be similarly effective.

Zinc plays an important role in tissue growth processes important for skin ulcer healing. One study reported that patients with pressure ulcers had lower blood levels of zinc and iron than did patients without pressure ulcers,¹⁴ and preliminary reports suggested zinc supplements could help some types of skin ulcer.¹⁵ Supplementation with 150 mg of zinc per day improved healing in a preliminary study of elderly patients suffering from chronic leg ulcers.¹⁶ Double-blind trials using 135 to 150 mg of zinc daily have shown improvement¹⁷ only in patients with low blood zinc levels,¹⁸ and no improvement in leg ulcer healing.¹⁹ ²⁰ A double-blind trial of 150 mg zinc per day in people with skin ulcers due to sickle cell anemia found that the healing rate was almost three times faster in the zinc group than in the placebo group after six months.²¹ Lastly, a preliminary study of patients with skin ulcers due to leprosy found that 50 mg of zinc per day in addition to anti-leprosy medication resulted in complete healing in most patients within 6 to 12 weeks.²² Long-term zinc supplementation at these levels should be accompanied by supplements of copper and perhaps calcium, iron, and magnesium. Large amounts of zinc (over 50 mg per day) should only be taken under the supervision of a doctor.

Topically applied zinc using zinc-containing bandages has improved healing of leg ulcers in double-blind studies of both zinc-deficient²³ and elderly individuals.²⁴ Most controlled comparison studies have reported that these bandages are no more effective than other bandages used in the conventional treatment of skin ulcers,²⁵ ²⁶ but one controlled trial found non-elastic zinc bandages superior to alginate dressings or zinc-containing elastic stockinettes.²⁷ Two controlled trials of zinc-containing tape for foot ulcers due to leprosy concluded that zinc tape was similarly effective, but more convenient than conventional dressings.²⁸ ²⁹

Pressure ulcers and diabetic ulcers frequently develop in malnourished and/or institutionalized people. A double-blind study³⁰ of malnourished people compared topical application of 20 ml of a solution containing essential fatty acids (EFAs) and linoleic acid extracted from sunflower oil with a control solution containing topical mineral oil. Each solution was applied to the skin three times per day. Compared with the control solution, the solution containing EFAs significantly reduced the incidence of pressure ulcers and improved the hydration and elasticity of the skin.

A preliminary report suggested that evening primrose oil improves blood flow to the legs and heals or reduces the size of venous leg ulcers.³¹ No controlled research has further investigated this claim.

A double-blind trial found that a combination of 900 mg per day of diosmin and 100 mg per day of hesperidin, two members of the flavonoid family, resulted in significantly greater healing of venous leg ulcers after two months.³² ³³ Related flavonoids known as hydroxyethylrutosides have also been investigated for venous ulcer healing. While one controlled study reported significant additional benefit when 2,000 mg per day of hydroxyethylrutosides were added to compression stocking therapy,³⁴ another double-blind trial using 1,000 mg per day found no effect on ulcer healing;³⁵ a second double-blind trial found no effect of 1,000 mg per day hydroxyethylrutosides on the prevention of venous ulcer recurrences.³⁶

Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful

Gotu kola (Centella asiatica) extracts are sometimes used topically to help speed wound healing. Test tube studies have found that extracts of gotu kola high in the active triterpene constituents asiaticosides, madecassoides, asiatic acids, and madecassic acids increase collagen synthesis.³⁷ ³⁸ An animal study found that topical application of asiaticoside isolated from gotu kola, used in a 0.2% solution, improved healing in nonulcer skin wounds.³⁹ An overview of three small human clinical trials suggests that topical use of an ointment or powder containing a gotu kola extract high in the active triterpene compounds may speed wound healing in people with slow-healing skin ulcers.⁴⁰ These studies used either a topical ointment with a 1% extract concentration or a powder with a 2% extract concentration. People in these studies were typically treated with intramuscular injections of either isolated asiaticosides or the mixed triterpenes three times per week while using the topical ointment or powder.

Aloe vera has been used historically to improve wound healing and contains several constituents that may be important for this effect. A group of three patients who had chronic skin ulcerations for 5, 7, and 15 years, respectively, had a rapid reduction in ulcer size after the application of aloe gel on gauze bandages to the ulcers, according to a preliminary report.⁴¹ A controlled study found most patients with pressure ulcers had complete healing after applying an aloe hydrogel dressing to the ulcers every day for ten weeks.⁴² However, this result was not significantly better than that achieved with a moist saline gauze dressing. The amorphous hydrogel dressing used in the above study and derived from the aloe plant (Carrasyn Gel Wound Dressing, Carrington Laboratories, Irving, TX) is approved by the U.S. Food and Drug Administration for the management of mild to moderate skin ulcers.

Are there any side effects or interactions?
Refer to the individual herb for information about any side effects or interactions.

Holistic approaches that may be helpful

A double-blind trial found systemic hyperbaric oxygen (HBO) treatments, in which the patient is placed in a chamber with highly concentrated oxygen, five days per week for six weeks significantly improved healing of nondiabetic chronic leg ulcers.⁴³ This trial confirms the results from several preliminary studies of systemic HBO therapy.⁴⁴ ⁴⁵ While topical application of HBO (the affected body part is encased in a balloon-like chamber and exposed to concentrated oxygen) for skin ulcers has been reported effective in preliminary trials,⁴⁶ controlled trials have produced conflicting results.⁴⁷ ⁴⁸ In controlled studies of diabetic patients with skin ulcers or gangrene, systemic HBO has been shown to prevent amputation of affected limbs.⁴⁹ ⁵⁰

Electrical stimulation applied to the skin is thought to have several biological effects that might accelerate skin ulcer healing.⁵¹ A variety of techniques have been investigated, and controlled or double-blind trials have shown positive results for the use of low-voltage galvanic current, high-voltage pulsed current, transcutaneous electrical nerve stimulation (TENS), and pulsed high-frequency electromagnetic therapy.⁵²

References
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1. Breslow RA, Hallfrisch J, Guy DG, et al. The importance of dietary protein in healing pressure ulcers. J Am Geratr Soc 1993;41:357–62.

2. Bourdel-Marchasson I, Barateau M, Rondeau V, et al. A multi-center trial of oral nutritional supplementation in critically ill older inpatients. Nutrition 2000;16:1–5.

3. Houwing R, Overgoor M, Kon M, et al. Pressure-induced skin lesions in pigs: reperfusion injury and the effects of vitamin E. J Wound Care 2000; 9:36–40.

4. Lucero MJ, Vigo J, Rabasco AM, et al. Protection by alpha-tocopherol against skin necrosis induced by doxorubicin hydrochloride. Pharmazie 1993;48:772–5.

5. Shukla A, Rasik AM, Patnaik GK. Depletion of reduced glutathione, ascorbic acid, vitamin E, and antioxidant defence enzymes in a healing cutaneous wound. Free Radic Res 1997;26:93–101.

6. Ramasastry, SS, Angel MF, Narayanan K, et al. Biochemical evidence of lipoperoxidation in venous stasis ulcer: Beneficial role of vitamin E as antioxidant. Ann NY Acad Sci 1989; 506–8.

7. Hajarizadeh H, Lebredo L, Barrie R, Woltering EA. Protective effect of doxorubicin in vitamin C or dimethyl sulfoxide against skin ulceration in the pig. Ann Surg Oncol 1994;1:411–4.

8. Goode HF, Burns E, Walker BE. Vitamin C depletion and pressure sores in elderly patients with femoral neck fracture. BMJ 1992;305:935–7.

9. Afifi AM, Ellis L, Huntsman RG, Said MI. High dose ascorbic acid in the management of thalassaemia leg ulcers—a pilot study. Br J Dermatol 1975;92:339–41.

10. Taylor TV, Rimmer S, Day B, et al. Ascorbic acid supplementation in the treatment of pressure cores. Lancet 1974;ii:544–6.

11. ter Riet G, Kessels AG, Knipschild PG. Randomized clinical trial of ascorbic acid in the treatment of pressure ulcers. J Clin Epidemiol 1995;48:1453–60.

12. Kopjas TL. Effect of folic acid on collateral circulation in diffuse chronic arteriosclerosis. J Am Geriatr Soc 1966;14:1187–92.

13. Taddeucci P, Pianigiani E, Colletta V, et al. An evaluation of Hyalofill-F plus compression bandaging in the treatment of chronic venous ulcers. J Wound Care 2004;13:202-4.

14. Williams CM, Lines CM, McKay EC. Iron and zinc status in multiple sclerosis patients with pressure sores. Eur J Clin Nutr 1988;42:321–8.

15. Greaves MW, Skillen AW. Effects of long-continued ingestion of zinc sulphate in patients with venous leg ulceration. Lancet 1970;2:889–91.

16. Carruthers R. Oral zinc sulphate in leg ulcers. Lancet 1969;1:1264.

17. Haeger K, Lanner E, Magnusson PO. Oral zinc sulfate in the treatment of venous leg ulcers. In: Pories WJ, Strain WH, Hwu JM, et al (eds), Clinical applications of zinc metabolism. Springfield, IL: CC Thomas, 1974, 158–67.

18. Hallbook T, Lanner E. Serum-zinc and healing of venous leg ulcers. Lancet 1972;2:780–2.

19. Greaves MW, Ive FA. Double-blind trial of zinc sulphate in the treatment of chronic venous leg ulceration. Br J Dermatol 1972;87:632–4.

20. Clayton RJ. Double-blind trial of oral zinc sulphate in patients with leg ulcers. Br J Clin Pract 1972;26:368–70.

21. Serjeant GR, Galloway RE, Gueri MC. Oral zinc sulphate in sickle-cell ulcers. Lancet 1970;2:891–3.

22. Mathur NK, Bumb RA. Oral zinc in the trophic ulcers of leprosy. Int J Lepr 1983;51:410–1.

23. Agren MS. Studies on zinc in wound healing. Acta Derm Venerol Suppl 1990;154:1–36.

24. Stromberg HE, Agren MS. Topical zinc oxide treatment improves arterial and venous leg ulcers. Br J Dermatol 1984;111:461–8.

25. Eriksson G. Comparison of two occlusive bandages in the treatment of venous leg ulcers. Br J Dermatol 1986;114:227–30.

26. Agren MS, Stromberg HE. Topical treatment of pressure ulcers. A randomized comparative trial of Varidase and zinc oxide. Scand J Plast Reconstr Surg 1985;19:97–100.

27. Stacey MC, Jopp-Mckay AG, Rashid P, et al. The influence of dressings on venous ulcer healing—a randomised trial. Eur J Vasc Endovasc Surg 1997;13:174–9.

28. Soderberg T, Hallmans G, Stenstrom S, et al. Treatment of leprosy wounds with adhesive zinc tape. Lepr Rev 1982;53:271–6.

29. Walton RT, Fritschi EP, Umapathy VA. Treatment of plantar ulcers in leprosy patients in the community with adhesive zinc tape. Lepr Rev 1986;57:53–6.

30. Declair V. Usefulness of topical application of essential fatty acids to prevent pressure ulcers. Ostomy Wound Management 1997;43:48–52.

31. Simpson LO, Hand BI, Olds RJ. Large leg ulcers, Efamol and hyperbaric oxygen. N Z Med J 1986;99:552 [abstract].

32. Guilhou JJ, Fevrier F, Debure C, et al. Benefit of a 2-month treatment with a micronized, purified flavinoidic fraction on venous ulcer healing. A randomized, double-blind, controlled versus placebo trial. Int J Micro Clin Exp 1997;17:21–6.

33. Guilhou JJ, Dereure O, Marzin L, et al. Efficacy of Daflon 500 mg in venous leg ulcer healing: a double-blind, randomized, controlled versus placebo trial in 107 patients. Angiology 1997;48:77–85.

34. Stegmann W, Hubner K, Deichmann B, Muller B. Efficacy of O-(s-hydroxyethyl)-rutosides in the treatment of venous leg ulcers. Phlebologie 1987;40:149–56 [in French].

35. Mann RJ. A double blind trial of oral O. B-hydroxyethyl rutosides for stasis leg ulcers. Br J Clin Pract 1981;35:79–81.

36. Wright DD, Franks PJ, Blair SD, et al. Oxerutins in the prevention of recurrence in chronic venous ulceration: randomized controlled trial. Br J Surg 1991;78:1269–70.

37. Marquart FX, Bellon G, Gillery P, et al. Stimulation of collagen synthesis in fibroblast cultures by a triterpene extracted from Centella asiatica. Connective Tissue Res 1990;24:107–20.

38. Tenni R, Zanaboni G, De Agostini MP, et al. Effect of the triterpenoid fraction of Centella asiatica on macromolecules of the connective matrix in human skin fibroblast cultures. Ital J Biochem 1988;37:69–77.

39. Shukla A, Rasik AM, Jain GK, et al. In vitro and in vivo wound healing of asiaticoside isolated from Centella asiatica. J Ethnopharmacol 1999;65:1–11.

40. Brinkhaus B, Linder M, Schuppan D, Hahn EG. Chemical, pharmacological and clinical profile of the East Asian medicinal plant Centella asiatica. Phytomedicine 2000;7:427–48.

41. Zawahry ME, Hegazy MR, Helal M. Use of aloe in treating leg ulcers and dermatoses. Int J Dermatol 1973;12:68–73.

42. Thomas DR, Goode PS, LaMaster K, Tennyson T. Acemannan hydrogel dressing versus saline dressing for pressure ulcers. A randomized, controlled trial. Adv Wound Care 1998;11:273–6.

43. Hammarlund C, Sundberg T. Hyperbaric oxygen reduced size of chronic leg ulcers: a randomized double-blind study. Plast Reconstr Surg 1994;93:829–34.

44. Wattel F, Mathieu D, Coget JM, Billard V. Hyperbaric oxygen therapy in chronic vascular wound management. Angiology 1990;41:59–65.

45. Lee HC, Niu KC, Chen SH, et al. Hyperbaric oxygen therapy in clinical application. A report of a 12-year experience. Chung Hua I Hsueh Tsa Chih (Taipei) 1989;43:307–16.

46. Landau Z. Topical hyperbaric oxygen and low energy laser for the treatment of diabetic foot ulcers. Arch Orthop Trauma Surg 1998;117:156–8.

47. Heng MC, Pilgrim JP, Beck FW. A simplified hyperbaric oxygen technique for leg ulcers. Arch Dermatol 1984;120:640–5.

48. Leslie CA, Sapico FL, Ginunas VJ, Adkins RH. Randomized controlled trial of topical hyperbaric oxygen for treatment of diabetic foot ulcers. Diabetes Care 1988;11:111–5.

49. Faglia E, Favales F, Aldeghi A, et al. Adjunctive systemic hyperbaric oxygen therapy in treatment of severe prevalently ischemic diabetic foot ulcer. A randomized study. Diabetes Care 1996;19:1338–43.

50. Baroni G, Porro T, Faglia E, et al. Hyperbaric oxygen in diabetic gangrene treatment. Diabetes Care 1987;10:81–6.

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52. Frantz RA. Adjuvant therapy for ulcer care. Clin Geriatr Med 1997;13:553–64 [review].

Learn more about Aisle7.

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The information presented in Aisle7 is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.

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