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What is a Venous Leg Ulcer?

We don’t treat ulcers, but an increasing number of persons are coming to the Clinic with them. A skin ulcer is where an area of skin has broken down, and you can see the underlying flesh. Venous leg ulcers are the most common type of skin ulcer. About 1 in 50 people develop one at some stage. They can be painless, but some are painful. Without treatment, an ulcer may become larger and cause problems in the leg.

Non-venous skin ulcers are less common. For example, a skin ulcer may be caused by poor circulation due to narrowed arteries in the leg, problems with nerves that supply the skin, or other issues. The treatment for non-venous ulcers is different to that of venous ulcers.

History for Predisposition to Venous Ulceration
The following are applicable:
• Pre-existing varicose veins
• Deep vein thrombosis
• Phlebitis
• Previous fracture, trauma or surgery
• Family history of venous disease
• Symptoms of venous insufficiency: for example, pains or heaviness in the legs, aching, itching, swelling, breakdown of the skin surface, pigmentation, eczema.
Features in the history which suggest a non-venous cause include:
• Family history of non-venous ulcers
• History of heart disease, stroke, transient ischaemic attack
• Diabetes mellitus
• Peripheral vascular disease or intermittent claudication
• Cigarette smoking
• Rheumatoid arthritis

Symptoms

Open wounds that have difficulty healing, which recur and have high infection rates. People who are diabetic, suffer from poor circulation or blood clotting disorders, or have poor valve function in the leg veins, are at high risk. Venous ulcers are commonly found below the knee but above the ankle, on the inner or side of the leg.

Edema and Surrounding Skin

The lower leg or foot may appear swollen when a leg ulcer is present. When pressed with a finger, the swollen areas hold the imprint of a finger for several seconds. Surrounding skin may appear a reddish brown or dark in colour. Patches of redness, skin flakes and weeping fluids similar to eczema may occur. The skin may feel firm to the touch and appear tight and shiny, depending on the amount of swelling, and may be hot. The surrounding skin may itch and remain uncomfortable. These symptoms are often associated with stasis dermatitis, a condition often diagnosed with the presence of venous ulcers.

Open Wound

Diabetic UlcerLeg ulcers have irregular shaped edges and often leak clear fluid. Additional signs of infection include a foul odour, fever and a growing ulcer, which could eventually produce a green or yellow discharge. A thin film of white or yellow tissue covers the wound opening.

 

Causes

Venous leg ulcers account for 90 percent of all leg ulcers. Conditions that affect the flow of blood in the veins of the legs can cause them.

Venous Insufficiency

Venous insufficiency describes a condition of impaired return blood flow from the legs to the heart. To facilitate this flow, the veins contain a series of valves to direct the blood upward. Contraction of the calf muscle helps to keep the blood flowing up the legs. Insufficiency occurs when the muscles fail to contract, or when the valves become damaged.

Chronic insufficiency causes feelings of fullness, heaviness, aching, cramps, or pain in the legs. The symptoms often worsen when standing or walking a lot. In addition the lack of blood flow in the lower legs can lead to stasis dermatitis, inflammation of the skin in the legs, leading to the formation of ulcers.

Venous Hypertension

This represents high blood pressure in the lower portion of the legs. This condition inhibits the flow of blood through the veins in the legs, such that damage to the valves in the veins, or an obstruction can cause fluid to accumulate in the lower leg leading to it. Venous hypertension causes inflammation of the tissue in the leg, and a decrease in the amount of oxygen reaching the cells in the leg, a condition known as hypoxia. These effects of the hypertension lead to the formation of the ulcers.

Inflammatory Diseases

Inflammatory diseases activate the immune cells in the body leading to an increased number of leukocytes, white blood cells. The white blood cells accumulate in areas of the body to fight the disease. When excess white blood cells build-up in the lower legs, they may obstruct the veins, increasing the blood pressure in the lower legs resulting in a venous leg ulcer. Several types of inflammatory diseases can cause venous leg ulcers, including lupus, scleroderma and rheumatological conditions.

Treatment

Options vary depending on the tissue damage present, and include closely monitored wound care, drainage, and use of antibiotics. Because venous ulcers are areas of the skin where tissue erosion has formed, the ulcer is concave in comparison to the surrounding skin. Recognising and treating them early, before they deteriorate to advanced stages, is critical.

Compression Therapy

This used in the initial stages and includes compression hose or wraps. The hose or wraps are formed around the leg area. The compression restricts the affected veins, increasing blood flow and reducing pooling of blood in the lower extremities. Tissue begins to heal because of the increased blood flow. The therapy often lasts several weeks to months depending on the severity of the wound.

Dressings and Wound Care

Topical dressings are applied to promote healing of the wound tissue. When dressings and wound care have to be done, it is critical to observe several factors. The wound’s diameter and depth should be measured if applicable. Note if any drainage is visible, and observe the colour and odour. Taking pictures of the ulcers is recommended, to track changes such as wound healing and decline.

Surgical Debridement

This is the removal of infected or dead tissue to encourage new tissue growth. Further complications are avoided if the leg ulcer is properly debrided. Complications include extreme pain or sepsis (bacterial infection of the blood), if the tissue remains in the wound. If sepsis occurs, an amputation of the lower extremity is a possibility.

Prevention

Primary prevention of venous insufficiency

Avoid prolonged standing or sitting; control risk factors – obesity, no smoking, etc; use compression hosiery on seeing early signs of venous insufficiency, eg stasis dermatitis. Help prevent the development of ulcers by observing these measures.

 

 

 

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