Leg ulcers

  • Definition
  • Wound Care
  • Patient Advice and Prevention
  • Products

leg-ulcers-01

Venous ulcer

This is the most common type of vascular ulcer.

  • Patients often have a history of lower limb oedema (swollen legs), varicose veins, or damaged leaking veins (venous insufficiency).
  • Or may have previously had thrombosis (blood clots) in either the superficial or the deep veins of their legs (post-thrombotic ulcers).

Venous leg ulcers occur predominantly on the lower limb above or in the vicinity of the malleolus (ankle).

The main clinical characteristics of venous leg ulcers are:

  • Shallow with irregular wound margins:
    • the skin around the ulcer is frequently discoloured
    • the presence of oedema may cause skin shininess and tightness of the surrounding skin
    • the skin temperature may be elevated to  touch
    • The ulcer itself may be:
      • red coloured with or without fibrin.
      • infected, the presence of discharge is suggestive of bacterial colonisation.
      • have significant exudate.

Important signs to look for include; lack of necrosis, non-deepening nature, presence of peripheral pulse.

  • 30 to 50% of all venous ulcers are post-thrombotic. Here the deep venous trunks (deep veins) are affected, unlike varicose ulcers, post-thrombotic syndrome develops gradually and will continue to deteriorate without treatment.
  • This type of ulcer is becoming less frequent due to improved prevention of phlebitis (vein inflammation) over the past 15 years.

Risk factors for venous ulcers include:

  • Hereditary factors of venous disease
  • Sedentary lifestyle, obesity
  • Age: more common over 60 years old
  • Female sex hormones
  • Micro-circulatory problems, (diabetes)
  • Renal failure
  • Working standing up for more than six hours per day leads to an increased incidence of varicose veins in both women and men.
  • Hypercoagulability of blood in the event of a thrombosis

Arterial ulcer

Arterial ulcers occur less frequently than venous ulcers.

Arterial ulcers arise distally (below) an area of external damage (knock, scrape or other injury) that often goes unnoticed by the patient:

  • On the foot, away from the ankle, heel or ball of the foot
  • Other pressure points

They occur in patients with:

  • peripheral arterial disease, arteriosclerosis, diabetes etc. as a result of poor arterial circulation.

Main clinical characteristics are:

  • round, smooth edges
  • deep “punched out” appearance with necrotic tissue
  • no odour
  • the foot often turns to a pale white/yellow colour when the leg is elevated
  • painful, especially at night exacerbated by raising the limb to a horizontal position (e.g. when in bed)
  • exposure of underlying structures

Risk factors for arterial ulcers include:

  • diabetes
  • smoking
  • high blood pressure
  • high cholesterol
  • obesity
  • family history of peripheral vascular disease or coronary heart disease.

Ulcer of mixed aetiology

Mixed ulcers are the result of a combination of both venous and arterial disease.
Mixed aetiology ulcers are complex and can change their character rapidly e.g. when the arterial disease is rapidly progressive.
If the arterial disease is left untreated because it is progressive the arterial problem will eventually be the major factor to consider when making treatment decisions.

Definition

Leg ulcers may be defined as an open lesion on the lower limb due to full thickness skin loss resulting in chronic wound progression. The ulcer may be surrounded by hard or discoloured tissue with reduced circulation, the state of the skin surrounding the ulcer is extremely important to the outcome, the healthier the surrounding area the greater the success of healing.

Ulcers tend not to heal spontaneously and often reoccur. This can be very incapacitating, especially if complications ensue.  Treating leg ulcers has a high societal cost both in terms of healthcare expenditure and psychological burden upon the patient.

Pathophysiology

Ulcers usually originate (95% of cases) from an arterial or venous circulatory disorder. The proportion of ulcers with a mixed arterial-venous origin has increased during the past few decades, as a result of an ageing population with concomitant arterial problems. This aetiology further complicates the healing.

Differential diagnosis

To determine the predominant origin of a mixed ulcer and/or make sure that there is no arterial disease present, the ankle-brachial pressure index (ABPI) should always be measured.

Ankle-brachial pressure index (ABPI)

Measures the arterial blood supply to the lower limb it is used to help determine the aetiology of a leg ulcer:

abpi

This measurement easily performed as an ambulatory test using a continuous Doppler probe or Doppler ultrasound blood flow detector:

  • In a healthy individual, the ABPI is 1.1.
  • If the ABPI is between 0.9 and 1.3: there is no arterial disease:
    • If an ulcer is present, it is of purely venous origin.
  • If the ABPI is between 0.7 and 0.9: there is concurrent arterial disease.
    • However the ulcer is predominantly venous in origin.
  • If the ABPI is less than 0.7:
    • the ulcer is of predominantly arterial origin.
  • In the event of an ABPI greater than 1.3, the measurement is not significant since this reflects an artery incompressibility problem.

Additional tests

For a complete assessment of the condition of the vascular system particularly in the lower limbs further examinations that are complementary to the clinical examination include:

  • Continuous Doppler
  • Colour Doppler Ultrasound
  • Angiography

Some conditions cause wounds that are similar in appearance to leg ulcers due to vascular complications. It is therefore very important that these different conditions are not confused since the appropriate treatment for one disease may be contraindicated for another one.

Other vascular causes are represented by hypertension (Martorell), diabetes, haematological and clotting disorders.

Rarer causes include vasculitis, pyoderma gangrenosum, infectious diseases, malignancies (carcinomas), calciphylaxis (diabetes) and drug-induced ulcers (hydroxyurea).

It is also important to observe carefully chronic ulcers caused by malignant diseases, these include:

  • Basal cell carcinoma
  • Squamous cell carcinoma
  • very rare skin metastases observed in systemic cancers.

Complications of ulcers

Complications resulting from leg ulcers include loss of mobility and the risk of infection. Immobility can make the ulcer worse, due to increased venous blood pressure (venous hypertension) and also increase the patient’s dependence and sense of isolation.

Occasionally long term infection can lead to conditions such as cellulitis or septicaemia. Unusually, if ulcers are present for many years a malignant tumour may arise (squamous cell carcinoma) with a poor prognosis.

For some patients the psychological impact of leg ulcers leads to anxiety and depression the mental health of the patient should be carefully monitored and the appropriate support provided if necessary.

Treatment of ulcers

If the underlying medical cause of the ulcer is known then it is essential to treat it.

Venous or mixed aetiology ulcer

  • Hypertension will respond to medication and weight reduction may also be implemented.
  • If exercise is possible a minimal regimen of moderate exercise will help improve the blood flow in the legs.
  • If the patient has diabetes then their blood sugar levels should be closely monitored and their treatment reassessed.
  • In the presence of venous incompetence, varicose vein surgery is effective in patients who can still receive this treatment

Arterial ulcers

In ulcers of arterial origin, revascularisation of the lower limb is the first treatment to propose: balloon angioplasty or stenting that relieves obstruction of the artery or by-pass surgery are procedures that should be considered.

Pain is an overriding problem in patients with arterial ulcers and this should always be addressed.

HEALING OF LEG ULCER IS BY SECONDARY INTENTION
OR DIRECTED HEALING
.

 

Venous ulcers

Predominantly venous ulcers will benefit from the use of compression. Compression is a simple, effective treatment that acts by squeezing the leg (by direct application of pressure, measured in mmHg) to stimulate venous return towards the heart and reduce oedema.

Compression bandaging is an integral part of wound healing and patients should understand the importance of concordance with this treatment.

Compression therapy

Compression therapy has been used since ancient times. It is still the cornerstone of treatment for phlebological and lymphatic conditions.

Compression is a simple, effective treatment that acts by squeezing the leg (by direct application of pressure, measured in mmHg) to stimulate venous return towards the heart and reduce oedema.

The level of pressure required depends on both the condition to be treated and the patient’s capacity to tolerate this pressure.

Indications for compression

Compression therapy has demonstrated efficacy:

  • in improving chronic venous disease,
  • in accelerating the healing rate of venous ulcers,
  • in the prevention and treatment of deep and superficial venous thrombosis and post-thrombotic syndrome,
  • in the optimisation of care following phlebology surgery,
  • in the correction and prevention of dynamic or mechanical lymphatic insufficiency (lymphoedema), etc.

The role of compression

Compression restores a normal venous flow from distal regions (extremities of the limbs) to proximal regions (roots of the limbs). It also aims to optimise the action of the venous muscle pump in order to restore the normal flow and direction of venous blood on exertion (from the superficial to the deep venous network and from distal to proximal tissues). Its use will accelerate and maintain the healing of leg ulcers of venous or mixed aetiological origin.

Compression

picto_compression

Protection of peri-wound skin

picto_repair

Preparation stage

If the wound is infected or heavily exuding/sloughy, dressings that purify or clean the wound should be chosen.

Products

picto_purify picto_clean

Healing stage

If the wound is not infected and is debrided then a dressing that ensures a moist wound healing environment and can accelerate healing in the presence of high levels of MMPs is possible. Dressings should be non-adhesive to ensure the integrity of the surrounding skin. A simple contact layer may be used under the compression bandages once healing has reached the epithelialisation stage.

Products

picto_accelerate picto_close

After healing

active-healed-ulcerOnce healing is complete, the site of the ulcer is a weak point in the skin and a potential risk for recurrence.

The compression bandage may be replaced by compression stockings which are easier for the patient to manage because their use may be necessary for several years depending on local protocols. Compression stockings must be correctly fitted for the patient’s leg size.

Products

Compression stocking ALTIFORM

 

Arterial ulcers

COMPRESSION SHOULD NEVER BE USED IN THE TREATMENT OF ARTERIAL ULCERS.

Preparation stage

Debridement may be required to remove necrotic tissue; hydrogel type dressings are suitable for this purpose.  NB If vascularisation is too severely impaired for a normal healing process, hydrogel dressings under occlusive dressings are contraindicated.

The ulcers should be monitored for the signs and symptoms of infection that may involve the soft tissues or bone.

Products

picto_purify picto_clean

Healing stage

Non-adhesive dressings are particularly useful for arterial ulcers to protect from external damage and to maintain a moist wound environment.

Healing can be accelerated by the use of dressings that combat the high damaging levels of MMPs in the wound.

At the epithelialisation stage, a simple contact layer may be used to protect the surface of the skin.

Products

picto_accelerate picto_close

Once healing is complete

TREATMENT OF THE UNDERLYING ARTERIAL PROBLEM SHOULD PREVENT RECURRENCE OF THE ULCER

 

Ulcers of mixed aetiology

If the patient’s ABPI is between 0.7 and 0.9 then reduced compression bandaging can be used as an integral part of wound healing depending on local protocols. Patients should understand the importance of concordance with this treatment.

Compression

picto_compression

Protection of peri-wound skin

picto_repair

Preparation Stage

If the wound is heavily exuding or infected dressings that purify or clean the wound should be chosen.

Products

picto_purify picto_clean

Healing stage

If the wound is not infected then a dressing that ensures a moist wound healing environment and can accelerate healing in the presence of high levels of MMPs is possible. Dressings should be non-adhesive to ensure the integrity of the surrounding skin.

A simple contact layer may be used under the compression bandages once healing has reached the epithelialisation stage.

Products

picto_accelerate picto_close

After healing

Once healing is complete, the site of the ulcer is a weak point in the skin and a potential risk for recurrence. The compression bandage may be replaced by compression stockings which are easier for the patient to manage because their use may be necessary for several years depending on local protocols. These must be correctly fitted for the patient’s leg size.

Products

Compression stockings ALTIFORM


These advices or recommendations do not replace expert opinion based on a full diagnosis.

Personal hygiene

Because of the high risk of infection patients should be persuaded to keep themselves and their environment as clean as possible. Regular washing and the use of clean clothes may be more difficult in older and immobile patients. The ulcers and the surrounding skin must never be touched without first washing the hands.

Skin care

Skin problems can occur with both venous and arterial disease and the skin needs to be protected as much as possible from the effects of trauma.

Patients with venous ulcers often suffer from local tissue ischaemia and trophic problems: atrophie blanche, varicose eczema, pigmented purpuric dermatitis, etc.

Patients should report any itching and discomfort which can be alleviated by the use of paraben-free, hypoallergenic emollients.

Recommendations

Patients should be encouraged to eat a healthy diet that contains a variety of fresh fruits, vegetables, dairy, grains and proteins and drink plenty of fluids.

Patients should be as active as possible and carry out their normal activities. Walking should be encouraged but patients should not stand still or sit for long periods.

For venous origin ulcers only the leg should be raised at night. This may be achieved by putting some pillows under the end of the mattress.


These advices or recommendations do not replace expert opinion based on a full diagnosis.
Last update : December 9, 2017