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Managing Lower Extremity Venous Ulcers



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Am Fam Physician. 2003 Aug 15;68(4):755.

Venous ulcers have a high prevalence and are more common in women than in men. The most frequent causes of lower extremity ulcers are venous insufficiency, arterial insufficiency, neuropathy (often related to diabetes), and ulcers from prolonged pressure and ischemia. Less common causes include trauma, inflammation, malignancy, metabolic conditions, and infections. Determining the underlying cause is important for successful ulcer treatment. De Araujo and associates reviewed the features and management of lower extremity venous ulcers.

Venous ulcers are usually located over the medial malleolus (gaiter area), and recurrence at the same location is common. The borders of the ulcers are generally irregular, flat, or slightly steep. Risk factors for development of these ulcers include a history of leg injury, obesity, phlebitis, a family history of varicose veins, types of employment or activities that require standing or sitting for long periods, deep venous thrombosis, and previous varicose vein surgery.

Symptoms of lower extremity venous ulcers include swelling and aching of the legs, often late in the day, which may improve with elevation of the limbs. Pain is a common complaint. Associated signs and symptoms may include dependent edema, varicose veins, a reddish-brown color, and purpura caused by erythrocyte extravasation with subsequent deposition of hemosiderin. Eczematous changes with redness, scaling, and pruritus (also known as venous dermatitis) are common and may be caused or worsened by topical medications.

Clinical criteria are most useful in evaluating leg ulcers and determining their cause (see accompanying table), although some patients may benefit from noninvasive studies. The ankle-brachial index, which compares the ankle and brachial systolic blood pressures, demonstrates peripheral arterial disease when the ratio is less than 0.97. In elderly patients and patients with diabetes, a transcutaneous oxygen measurement may be more useful for assessing arterial flow. The gold standard for evaluating the venous and arterial systems is color duplex ultrasonography. Radiographic bone scanning is appropriate when osteomyelitis is being considered. Probing of sinuses and deep ulcers can identify bone infection in patients with diabetic foot ulcers. In patients with longstanding wounds (more than three months), biopsy should be performed to evaluate for malignancy or atypical infection.

Treatment goals for patients with venous ulceration include decreasing edema, reducing pain, improving lipodermatosclerosis, healing the ulcer, and preventing recurrence. Frequent leg elevation above the heart level (for 30 minutes, three to four times a day) is most useful in patients with venous insufficiency.

Graduated compression therapy to overcome venous hypertension is useful and can be applied using inelastic or elastic bandages. An inelastic bandage such as the Unna boot (a moist, pasty bandage that hardens to inelasticity) applies more pressure with activity. However, this type of bandage does not absorb highly exudative wounds and cannot constrict to accommodate a lessening of the edema. Thus, Unna boots must be reapplied frequently. Elastic bandages sustain pressure, conform to the leg better, are easier to use, and require fewer bandage changes. However, these bandages require multilayering and skilled application. Compression therapy should be used with caution in patients with cardiac insufficiency, because of the resulting increase in cardiac preload. Treatment with compression bandages should be used until the ulcer is healed. Ulcer recurrence is less common when patients continue compression therapy with graded stockings.

Clinical Aspects of the Most Common Types of Ulcers of the Lower Limbs

Wound type General information Pathophysiology Clinical features Therapy

Venous ulcers

Most common type of leg ulcers; women affected more than men; often, elderly patients

Venous hypertension

Presence of varicosities; ulcer located in the gaiter area; shallow, painful; granulation tissue and fibrin present

Leg elevation, compression therapy, aspirin, pentoxifylline, tissue-engineered skin, growth factors

Associated findings include edema, venous dermatitis, and lipodermatosclerosis.

Arterial ulcers

Elderly patients with history of cardiac or cerebrovascular disease; leg claudication, impotence, pain in distal foot

Tissue ischemia

Ulcers commonly deep, located over bony prominences; round or punched out with sharply demarcated borders, yellow base, or necrosis; exposure of tendons

Revascularization, antiplatelet and other rheologic agents; address risk factors.

Concomitant venous disease in up to25 percent of cases

Associated findings include abnormal pedal pulses, cool limbs, femoral bruit, and prolonged venous filling time.

Neuropathic ulcers

Most common cause of foot ulcers, most frequently caused by diabetes

Trauma, prolonged pressure

Usually plantar aspect of feet in patients with diabetes, neurologic disorders, or Hansen's disease (leprosy)

Offloading; topicallyapplied growth factors; tissue-engineered skin

Pressure ulcers

Usually bed-ridden patients; monoplegia

Tissue ischemia and necrosis secondary to prolonged pressure

Located over bony prominences in patients with limited mobility

Offloading; adequate nutrition, reduction of excessive moisture, shear, and friction

Risk factors include excessive moisture and altered mental status.


Reprinted with permission from de Araujo T, Valencia I, Federman DG, Kirsner RS. Managing the patient with venous ulcers. Ann Intern Med 2003;138:327.

Clinical Aspects of the Most Common Types of Ulcers of the Lower Limbs

View Table

Clinical Aspects of the Most Common Types of Ulcers of the Lower Limbs

Wound type General information Pathophysiology Clinical features Therapy

Venous ulcers

Most common type of leg ulcers; women affected more than men; often, elderly patients

Venous hypertension

Presence of varicosities; ulcer located in the gaiter area; shallow, painful; granulation tissue and fibrin present

Leg elevation, compression therapy, aspirin, pentoxifylline, tissue-engineered skin, growth factors

Associated findings include edema, venous dermatitis, and lipodermatosclerosis.

Arterial ulcers

Elderly patients with history of cardiac or cerebrovascular disease; leg claudication, impotence, pain in distal foot

Tissue ischemia

Ulcers commonly deep, located over bony prominences; round or punched out with sharply demarcated borders, yellow base, or necrosis; exposure of tendons

Revascularization, antiplatelet and other rheologic agents; address risk factors.

Concomitant venous disease in up to25 percent of cases

Associated findings include abnormal pedal pulses, cool limbs, femoral bruit, and prolonged venous filling time.

Neuropathic ulcers

Most common cause of foot ulcers, most frequently caused by diabetes

Trauma, prolonged pressure

Usually plantar aspect of feet in patients with diabetes, neurologic disorders, or Hansen's disease (leprosy)

Offloading; topicallyapplied growth factors; tissue-engineered skin

Pressure ulcers

Usually bed-ridden patients; monoplegia

Tissue ischemia and necrosis secondary to prolonged pressure

Located over bony prominences in patients with limited mobility

Offloading; adequate nutrition, reduction of excessive moisture, shear, and friction

Risk factors include excessive moisture and altered mental status.


Reprinted with permission from de Araujo T, Valencia I, Federman DG, Kirsner RS. Managing the patient with venous ulcers. Ann Intern Med 2003;138:327.

Other treatments that increase the healing rate for venous ulcers include medications such as aspirin and pentoxifylline. Surgical interventions include skin grafting and less well-proven procedures such as debridement (chemical or physical) and vein surgery. Successful wound closure has been achieved with skin equivalents (tissue-engineered skin). Studies are being conducted on the use of topical and perilesional injections of growth factors to promote healing. Patients with nonhealing ulcers (large, long duration, not responsive after one month of treatment) should be referred to a team of specialists.

The authors conclude that venous ulcers are a common and costly problem. Early diagnosis and recognition of prognostic factors can facilitate optimal management.

De Araujo T, et al. Managing the patient with venous ulcers. Ann Intern Med February 18, 2003;138:326–34, and Cullum N, et al. Compression for venous leg ulcers. Cochrane Database Syst Rev 2003;1:CD000265; Mani R, et al. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database Syst Rev 2003;1:CD001899; Jull AB, et al. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst Rev. 2003;1:CD001733.

editor's note: The management of venous leg ulcers is a frequent concern for family physicians. Several common treatments have been thoroughly evaluated for efficacy. Cochrane reviews document the usefulness of compression, with multilayered systems being more effective than single-layer systems and high compression being better than low compression. The major risk of compression—reduced blood supply to the skin that results in irritation or damage—can be avoided by evaluating the peripheral arterial supply. Intermittent pneumatic compression may augment the efficacy of compression therapy, but further studies are needed. Pentoxifylline may be a useful adjunct to compression bandaging and may be useful alone when bandaging is contraindicated. Other interventions, including electrical stimulation, laser therapy, and ultrasound therapy, have been used, but their efficacy has not been well documented.—r.s.

 

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