Chronic Leg Ulcers: Epidemiology Aetiopathogenesis And Management
Shubhangi Vinayak Agale
1Department of Pathology, Grant Govt Medical College, Byculla, Mumbai 400008, India
Chronic leg ulcer is defined as a defect in the skin below the level of knee persisting for more than six weeks and shows no tendency to heal after three or more months. Chronic ulceration of the lower legs is a relatively common condition amongst adults, one that causes pain and social distress. The condition affects 1% of the adult population and 3.6% of people older than 65 years. Leg ulcers are debilitating and greatly reduce patients’ quality of life. The common causes are venous disease, arterial disease, and neuropathy. Less common causes are metabolic disorders, hematological disorders, and infective diseases. As many factors lead to chronic lower leg ulceration, an interdisciplinary approach to the systematic assessment of the patient is required, in order to ascertain the pathogenesis, definitive diagnosis, and optimal treatment. A correct diagnosis is essential to avoid inappropriate treatment that may cause deterioration of the wound, delay wound healing, or harm the patient. The researchers are inventing newer modalities of treatments for patients with chronic leg ulceration, so that they can have better quality life and reduction in personal financial burden.
4. Pathogenesis of Chronic Leg Ulcers
4.1. Venous Ulcers
4.2. Arterial Ulcers
4.3. Diabetic Foot Ulcer
Getting A Specialist Vascular Referral
If you have venous hypertension, intervention to your veins from a vascular specialist might help with healing and stop your wound or sore from coming back. Sometimes varicose veins can be treated by laser therapy. If you have peripheral arterial disease, you may require further investigations and the vascular team will be able to assess the need to improve the blood supply to your leg or whether your ulcer can be managed in other ways such as reduced/modified compression. Ask your nurse or doctor for a referral to your local vascular team to talk about how their input might help you.
Compression Treatment Of Leg Ulcers: A Systematic Review
To estimate the clinical and cost effectiveness of compression systems for treating venous leg ulcers, 19 electronic databases including Medline, CINAHL, Embase, relevant journals, and conference proceedings included 24 randomised controlled trials which demonstrated that compression systems improve healing of venous leg ulcers and should be routinely used in uncomplicated venous ulcers. High compression is more effective than low compression, but should only be used in the absence of significant arterial disease. There are no clear differences in the effectiveness of different types of compression systems have been shown. Intermittent pneumatic compression appears to be a useful adjunct to bandaging. Rather than advocate one particular system, the increased use of any correctly applied high compression treatment should be performed. Compression bandages and stockings in the treatment of venous leg ulcers as reviewed by Cochrane Wounds Review Group, demonstrated that multilayer high compression bandages were significantly more effective than a single layer bandage. The direct comparisons of the healing rates were described in the two observational studies as 40% in 12 weeks and 42% of people attending a leg ulcer clinic. The limitations for use of four layer bandaging in a community clinic include the fact that some people are unable to leave their home due to immobility and cannot tolerate or do not like the treatment.
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Can You Prevent Venous Insufficiency
If you have a family history of venous insufficiency, there are steps you can take to lessen your chances of developing the condition:
- Dont sit or stand in one position for long stretches of time get up and move around frequently.
- Dont smoke and if you do smoke, do everything you can to quit.
- Maintain a healthy body weight.
Take these steps to prevent the development of venous leg ulcers, especially if you are at a higher risk. Also, if an ulcer does develop, talk to your doctor right away.
Can Leg Ulcers Be Prevented
To prevent and promote healing of ulcers:
- Avoid injury, particularly when pushing a supermarket trolley. Consider protective shin splints.
- Walk and exercise for at least an hour a day to keep the calf muscle pump working properly.
- Lose weight if you are overweight.
- Stop smoking.
- Check your feet and legs regularly. Look for cracks, sores or changes in colour. Moisturise after bathing.
- Wear comfortable well-fitting shoes and socks. Avoid socks with a tight garter or cuff. Check the inside of shoes for small stones or rough patches before you put them on.
- If you have to stand for more than a few minutes, try to vary your stance as much as possible.
- When sitting, wriggle your toes, move your feet up and down and take frequent walks.
- Avoid sitting with your legs crossed. Put your feet up on a padded stool to reduce swelling.
- Avoid extremes of temperature such as hot baths or sitting close to a heater. Keep cold feet warm with socks and slippers.
- Consult a chiropodist or podiatrist to remove a callus or hard skin.
- Wear at least Grade 2 support stockings if your doctor has advised these. This is particularly important for the post-thrombotic syndrome, leg swelling or discomfort, and for long-distance flights.
- Have a vascular ultrasound assessment and consult a vascular surgeon to determine whether any vein treatment should be carried out.
- Horse chestnut extract appears to be of benefit for at least some patients with venous disease.
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Can You Claim For A Sepsis Death
To find out whether your loved one died because of negligent medical care, you need to talk to a solicitor who specialises in clinical negligence claims. A solicitor will be able to tell you whether there was a substandard level of care, whether this affected the eventual outcome, and whether you are able to pursue legal action against the GP or hospital at fault.
Although making a claim cannot undo the harm that has been done, it may help to provide some form of redress. It will also ensure you can recover the finances lost because of the negligence, something which will be very important for a spouse or children who were dependent upon the deceased’s income/pension.
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Mrs O, South Wales.
Healthcare Advice For Leg Ulcers
There are some lifestyle changes you can make that will help boost healing:
- Maintain a healthy weight
- Eat a well-balanced diet that includes 5 portions of fruit and vegetables a day and protein rich foods such as eggs, fish, chicken or pulses
- Take light to moderate exercise such as cycling or walking for about thirty minutes at least three times a week
- Avoid standing or sitting for long periods of time
- Put your feet up elevate your legs above your heart.
- Every so often, move your feet around in circles, then up and down. This helps blood circulate and get back to your heart
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Management Of Diabetic And Neuropathic Ulcers
The following instructions should be given to the patient:
Regularly inspect the legs/feet for scratch marks, blisters, etc
Wash the feet with warm water daily followed by careful drying between the toes
Apply emolients, for example, Vaseline on the dry skin but not between the toes
Inspect shoes regularly
It is useful to see a chiropodist regularly
Avoid sandals and pointed shoes which may lead to foot trauma
Never walk bare footed
See your doctor regularly if there is any injury or blister of the leg/feet
Radiography of the affected areasfor example, spiral computed tomography and/or magnetic resonance imaging should be performed to exclude osteomyelitis and also air within the soft tissues should be looked for to confirm the presence of gas forming organisms. Radionucleide bone scan, gallium scan, and bone biopsy may be necessary to confirm a diagnosis of osteomyelitis.
Once infection is controlled a decision can be made as to whether the patient needs vascular surgical treatment. Biopsy should be done for chronic non-healing ulcers. Biopsy of the ulcer edge certainly seems to be a procedure which can be performed at no risk to the patient. It has been suggested that biopsy of the ulcers that have not improved after three months of treatment should be performed to exclude squamous cell carcinoma, basal cell carcinoma, or vasculitis. If squamous cell carcinoma is suspected, a wedge rather than a standard punch biopsy should be performed.
Looking After Yourself During Treatment
To help your ulcer heal more quickly, follow the advice below:
- Try to keep active by walking regularly. Sitting and standing still without elevating your legs can make venous leg ulcers and swelling worse
- Whenever you’re sitting or lying down, keep your affected leg elevated with your toes level with your eyes
- Regularly exercise your legs by moving your feet up and down, and rotating them at the ankles. This can help encourage better circulation
- If you’re overweight, try to reduce your weight with a healthy diet and regular exercise
Read more about preventing venous leg ulcers.
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How Is Venous Insufficiency Diagnosed
Your doctor will want to do a physical examination and take a complete medical history to figure out if you have venous insufficiency. They may also order some imaging tests to pinpoint the source of the problem. These tests may include a venogram or a duplex ultrasound.
Venogram. Your doctor will put an intravenous contrast dye into your veins. Contrast dye causes the blood vessels to appear opaque on the X-ray image, which helps the doctor see them on the image. This dye will provide your doctor with a clearer x-ray picture of your blood vessels.
Duplex ultrasound. A type of test called a duplex ultrasound may be used to test the speed and direction of blood flow in the veins. A technician will place gel on the skin and then press a small hand-held device against your skin. The transducer uses sound waves that bounce back to a computer and produce the images of blood flow.
Ulceration Due To Dermatitis Artefacta
Ulceration secondary to artefact may be difficult to diagnose. Clinical suspicion might be raised by the following: unusual appearance, unusual site, after trauma at work with possible compensation issues, angulate shape or the apparent indifference of the patient to their ulcer and its implication to their life. If the ulcer tends to come and go, a skin biopsy may be necessary to show up out-side-in damage, that is, disproportionate damage to the epidermis compared with the dermis.
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Causes Of Venous Ulcers
Venous ulcers most often form around the ankles.
Venous ulcers typically occur because of damage to the valves inside the leg veins. These valves control the blood pressure inside the veins. They allow it to drop when you walk. If the blood pressure inside your leg veins doesn’t fall as you’re walking, the condition is called sustained venous hypertension. That increase in blood pressure causes ulcers to form on your ankles.
Venous ulcers may also be caused by other problems with your leg veins. These include:
Varicose veins. These are large, bulging leg veins. They occur when valves in the leg veins dont work well, allowing blood to collect in the lower leg.
Chronic venous insufficiency. Like varicose veins, this condition occurs when your leg veins cant pump blood back up to your heart. Blood then pools in your lower legs, causing your legs to swell. Since the blood can’t flow well in your legs, the swelling may be extreme. This extreme swelling can put so much pressure on your skin that venous ulcers form.
What Does A Venous Leg Ulcer Look Like And What Causes Them
Venous leg ulcers are sores that develop between your knee and ankle, but they typically form inside the leg near or around the ankle. They are large, shallow ulcers with uneven edges that drain or weep a lot.
Youll likely see swelling in your leg, with red, itchy skin around the wound. You may also experience tightness in your calves, as well as aching, throbbing or a feeling of heaviness in your legs. Pooled and trapped blood often causes discolored splotches in the area.
The sores sometimes affect only the skin or they may sink deeper into the fat layer, muscle, tendon and bone, she says. Severe ulcers are more likely to become infected and take longer to heal.
Your veins carry blood back to your heart, and valves in the veins stop the blood from flowing backward. When your veins have trouble sending blood from your limbs to the heart, its known as venous insufficiency. In this condition, blood doesnt flow back properly to the heart, causing blood to pool in the veins in your legs.
Our veins are just like pipes, says Ehren. When theres persistently high blood pressure in the veins of the legs with a valve that doesnt work correctly, it causes damage to the skin, which eventually breaks down and forms an ulcer.
Other possible causes for venous leg ulcers include:
- Varicose veins.
- Swelling of a superficial vein .
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What Causes Ankle Ulcers
Venous stasis ulcers are typically due to a condition called venous hypertension or chronic venous insufficiency. Your blood doesnt flow from your lower legs back to your heart as it should. This causes a buildup of pressure in your veins. The additional pressure can lead to an ulceration on your skin. These usually form on the inside of your legs, just above your ankle.
Its unknown exactly how this condition causes ulcers. Many doctors believe it also causes a decrease in blood flow to the capillaries of your legs. This produces a buildup of white blood cells. The accumulation of white blood cells restricts oxygen to your tissue. The lack of oxygen causes damage and forms the ulcer.
Another theory is that venous hypertension causes cells from elsewhere in the body to leak into your skin and influence cellular growth. This process interferes with the repair of damaged tissue.
You may have a higher risk of developing venous stasis ulcers if you have or had:
- previous leg swelling
- varicose veins
- a history of inflammatory diseases
If you have a family history of ulcers, its possible youll develop them too. Smoking may also raise your risk of developing ankle ulcers because it interferes with the flow of oxygen through your bloodstream.
Complications Of Venous Leg Ulcers
Venous leg ulcers are difficult to treat, and when they are present a variety of complications may arise. These complications can be challenging to treat and may often contribute to the prolonged healing times resulting from chronicity found with many VLUs. Further, if the condition of the ulcer deteriorates, it may worsen any complication already present or serve as the catalyst for the development of complications.
Treatment What Treatment Will I Be Offered For My Leg Ulcer
If your wound isnt healing because of venous hypertension and there are no problems with the blood supply to your legs, then you should be offered compression therapy.
Compression therapy improves blood supply by applying pressure to the leg. This can be done by bandaging the lower leg or by wearing supportive socks, stockings or tights. Compression therapy is very effective at reducing swelling, improving blood flow in the veins and healing or preventing sores or ulcers.
There are lots of different types of compression therapy so ask your nurse to find something that is right for you.
Compression can be a little uncomfortable when you first start treatment but should not cause you any pain. Any discomfort should reduce as the swelling goes down. If you do experience discomfort, talk to your nurse or doctor about it and they will advise you on ways of alleviating this.
In addition to the compression, your nurse should also advise you on wound care and dressings to keep your wound healthy.
Leg Ulcers In Older People: A Review Of Management
Adeyemi Adeyi, Sharon Muzerengi and Indrajit Gupta
Leg ulcers are a common presentation in the elderly population associated with a negative impact in the quality of life. Several factors including venous and arterial insufficiency, immobility and obesity all contribute to an increased incidence in this age group. A thorough assessment including comprehensive history of ulcer development, examination of the ulcer site, size, shape, appearance and vascular assessment with Doppler ultrasound are all essential in deciding type of treatment. Various treatment modalities are available for the management of different types of leg ulcers although no clinical trials comparing the efficacy of one treatment over the other have been done. Some of them have not got strong evidence to show that they actually improve healing, still awaiting further research.
|Aetiology of ulcer|
|Basal cell , squamaous cell carcinoma, melanoma|
|Neuropathic||Common in diabetes, wet, deep, sharp borders on pressure points|
|Ulcer||SiteAppearanceSize-measureWound baseExudate levelSurrounding skin|
|1 wool padding1 high elastic bandage1 cohesive bandage|
|Greater than 30cm||1 wool padding1 light elastic bandage 1 high elastic bandage1 cohesive bandage|
- Patient fit for surgery
- Sufficient mobility to activate calf muscle pump
- Prepared to attend hospital for investigation and surgery
- Obesity controlled
- Superficial venous incompetence
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