83 year old male referred to agency CWOCN after 12 months of standard care for > 6 year old bilateral venous leg ulcers. PMH includes IDDM and recurrent lower extremity fungal infections. Ulcers responded variably to standard 3-layer compression over a period of five years then deteriorated significantly. Patient was referred to a new local wound care center.  Conservative sharps debridement, silver dressings, and 3-layer compression were performed at local wound care center with varying success over twelve months; then wound center closed. Follow up home health orders consisted of cleaning with antibacterial soap, rinsing with saline, silver sheet dressings, and 3-layer compression twice weekly.  CWOCN referral was made when ulcers deteriorated and pain levels increased to 8/10. Because periwound epithelium sloughed continuously and wound margins were so irregular, standard measuring tools were not feasible. It was decided that progress would be evaluated by photo documentation by CWOCN weekly.  After in home assessment and ABI, new treatment of thorough cleansing with tap water and non-antibacterial soap(restore and maintain acidic pH of skin), saline rinse, antimicrobial cellulose dressing(hydrate and absorb exudate, maintain moist wound environment), petroleum gauze(prevent adherence), and Unna boots(ABI 0.7 with long term IDDM: arterial involvement not ruled out) was implemented twice weekly. After 14 days of treatment, pain levels were decreased to 2/10, periwound was clear, wound beds were 100% granulation, edges were open, standard measuring tools were again implemented, and pain medication was reduced to half of original dose. In this case, the standard of care had not been effective. Creativity and critical thinking while incorporating each aspect of the wound topically, the patient systemically, and previous treatments was needed to achieve successful outcomes and improve the quality of life for this venous leg ulcer patient.