Venous insufficiency and ulcers Quiz: Ace Your Exams

A 68-year-old man presents to the clinic for follow-up evaluation of bilateral lower extremity edema. The patient’s last visit was six weeks ago. At that time, venous duplex ultrasound showed pathologic reflux within multiple veins bilaterally. The patient reports wearing compression stockings as prescribed and has been elevating his legs whenever possible. The patient continues to have moderate swelling, which is causing significant discomfort. Additionally, the patient has developed small, open skin lesions above both ankles that have not healed over the last 2 weeks. Temperature is 37.0°C (98.6°F), heart rate is 68/min, respiratory rate is 14/min, blood pressure is 120/78 mmHg, and oxygen saturation is 100% on room air. On physical examination, there are multiple small ulcerations with irregular borders on the medial aspect of the bilateral lower legs. No warmth, erythema, or purulent drainage is noted. There is significant pitting edema with overlying brawny, hyperpigmented skin. Pulses are full and equal bilaterally. Ankle-brachial index is measured and is > 0.9 bilaterally. What is the best next step in management of this patient?