Лечение хронических заболеваний вен нижних конечностей

ГЛАВА 9.
Топическая терапия в лечении трофических язв

Топические агенты и повязки, способствующие скорейшему отторжению некротических тканей, появлению грануляций и эпителизации венозных язв голени, приобрели за последнее время широкое распространение в клинической практике. Гидрогели, альгинатные повязки, гидроколлиоды, ферментные агенты, ростовые факторы, гели с аминокислотами и тромбоцитами, пленки с фибрином составляют арсенал возможностей для лечения трофических язв. 1 ^- 50 Эквиваленты кожи с культурами кератиноцитов и фибробластов, как было показано, также ускоряют заживление язв. 51 ^- 64 Однако до сих пор не существует I уровня доказательности, что подобная терапия имеет преимущество перед простыми раневыми повязками и компрессионной терапией.

Использование местных антибактериальных препаратов у больных с трофическими язвами считается нецелесообразным из-за появления в зоне их воздействия резистентных микроорганизмов и повышения риска контактного дерматита. 11, 65 В настоящее время нет также данных в поддержку рутинного системного введения антибиотиков для ускорения заживления язвы. Показанием для применения антибактериальной терапии является развитие инфекции мягких тканей на фоне трофических нарушений. В свете существующей проблемы появления резистентной микрофлоры назначение этих препаратов в соответствии с современными рекомендациями производится при появлении клинических признаков развития бактериальной инфекции. Обнаружение колонизации микрофлоры в данной зоне без клинических проявлений не является показанием.

Существует ряд доказательств в пользу использования повидон йодина, октенидина, фенотиона, кристацида, сукральфата, этакридин лактата, мупироцина и хлоргексидина, веществ на основе пероксида, кислорода в лечении венозных язв. 66 ^- 74 Местные антисептики обладают токсическим эффектом на клетки, что обусловливает их антибактериальный эффект, но, вместе с тем, нарушают эпителизацию раны. 75

Существуют доказательства, что гиалуроновая кислота и амниотическая мембрана обладают положительным эффектом на заживление язв. 76 ^- 80

В течение последних нескольких лет физические методы лечения с использованием отрицательного давления в области трофической язвы приобретают все большее распространение, собирая доказательства о положительном эффекте подобного лечения. 81 ^- 86

Электростимулирующая терапия, электромагнитная терапия, ультразвуковое воздействие низкой и высокой частоты, лазерное и инфракрасное излучение также способствуют заживлению язв, особенно длительно не заживающих, рефрактерных к рутинной терапии. 87 ^- 101 Экстракорпоральное ударно волновое воздействие стимулирует, как было показано в исследованиях, заживление язв. Однако все данные об эффективности данных методов лечения основаны на оценке случаев из практики или малых выборках больных.

В купированнии болевого синдрома при лечении трофических язв помогает, как было показано, применение ибупрофена медленного высвобождения. 104 ^- 107

Некоторые авторы отстаивают применение личинок для очищения язв. 108 ^- 111 Встречаются даже предложения по использованию меда для местного лечения. 112 ^- 115

Хотя существует огромное количество различных публикаций о лечении язв доказательства не очевидны в отношении эффективности и стоимости лечения. Для получения неопровержимых доказательств необходимо продолжить подобные исследования.

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