Venous leg ulceration

Epidemiology:

• 80-85% of leg ulcers are of venous origin
• 70% of those with active ulcers are >70 years of age
• Female:male ratio of 3:1

Aetiology:

• Oedema from venous HT and raised pressure at the venular end of the capillary loop, skin and subcutaneous hypoxia are and an episode of minor trauma are the usual pathological antecedents of ulceration
• They are most likely to occur when there is damage to the valves of the deep veins, but long-standing superficial HT caused by deep to superficial incompetence alone is also a well recognised cause
• Once an ulcer is established, healing of the poorly nourished skin is difficult and granulation tissue and a fibrous base develops
• The build-up of fibrosis with reduced input into the tissue from the arterial side of the circulation is a further impediment to healing
• Secondary infections by skin residents such as staphylococci are common

Causes of ulceration of the leg:

• Venous disease
• Arterial disease
• Trauma
• Rheumatoid arthritis
• Pyoderma gangrenosum
• Systemic sclerosis
• Malignant disease
• Diabetes mellitus
• Blood disorders (e.g. sickle cell disease)

Clinical features:

• The lesion occurs almost exclusively just above or in relation to the medial malleolus
• It is usually:
• Oval
• Flat, without a raised edge
• Looks relatively healthy
• Has a granulating base
• Concomitant infection (with either surrounding erythema or extensive cellulitis) may be present

Distinctive characteristics of venous and arterial ulcers:

Venous Arterial

History Previous DVT, varices Intermittent claudication, IHD, HT, DM

Pain Uncommon Nearly always present, worse at night

Site usually medial malleolus Toes, heel, foot, lateral aspect

Size Variable, increases slowly Variable but increases rapidly

Oedema Common, worse at night Uncommon

Skin Pigmentation, white patches Shiny, thin, atrophic nails

Temperature Usually warm Cool

Foot pulses Present Reduced or absent

Management:

Most venous ulcers which are correctly diagnosed and treated early respond readily to conventional treatment, but even relatively small lesions can take up to 3 months to heal. More chronic lesions require a more precise regimen, as follows:

Step 1:

• Establish if there is correctable superficial venous HT which is the consequence of deep to superficial incompetence only
• If this is so, surgery is indicated

Step 2:

• If there are multiple points of incompetence or, what almost always amounts pathophysiologically to the same thing , deep venous damage, the starting point is non-operative management
• The majority of leg ulcers fall into this category
• The essential component is to apply effective compression to the limb and sustain it until the ulcer has healed
• All venous ulcers heal if the patient is confined to bed with the foot elevated above the heart so that venous HT is abolished, the microenvironment improved and healing promoted
• However, bed rest is a costly and, therefore, usually inappropriate method
• Adequate local compression in a patient who is otherwise mobile is an effective alternative

Step 3:

This runs concurrently with steps 1 and 2

Is local management of the lesion

The inappropriate use of topical agents, included impregnated bandages, prescribed by either a physician or a nurse should be AVOIDED

Dressings are kept simple and pharmacologically active substances applied only for specific and logical reasons – which means hardly ever

Systemic antibiotic therapy is only indicated if there is spreading cellulitis – topical applications are ineffective in controlling contamination unless the causes of the ulcer are dealt with

Surgical measures in ulceration:

• Severely contaminated long-standing ulcers with infected granulation tissue at the bas may benefit from surgical debridement before non-operative treatment is begun