Venous Ulcers: Diagnosis and Treatment

 

Am Fam Physician. 2019 Sep 1;100(5):298-305.

  Patient information: See related handout on venous ulcers.

Author disclosure: No relevant financial affiliations.

Venous ulcers are the most common type of chronic lower extremity ulcers, affecting 1% to 3% of the U.S. population. Venous hypertension as a result of venous reflux (incompetence) or obstruction is thought to be the primary underlying mechanism for venous ulcer formation. Risk factors for the development of venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis, and venous reflux in deep veins. Poor prognostic signs for healing include ulcer duration longer than three months, initial ulcer length of 10 cm or more, presence of lower limb arterial disease, advanced age, and elevated body mass index. On physical examination, venous ulcers are generally irregular and shallow with well-defined borders and are often located over bony prominences. Signs of venous disease, such as varicose veins, edema, or venous dermatitis, may be present. Other associated findings include telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg. Chronic venous ulcers significantly impact quality of life. Severe complications include infection and malignant change. Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products. Referral to a wound subspecialist should be considered for ulcers that are large, of prolonged duration, or refractory to conservative measures. Early venous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates.

Venous ulcers are open skin lesions that occur in an area affected by venous hypertension.1 The prevalence of venous ulcers in the United States ranges from 1% to 3%.2,3 In the United States, 10% to 35% of adults have chronic venous insufficiency, and 4% of adults 65 years or older have venous ulcers.4 Risk factors for venous ulcers include age 55 years or older, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, lower extremity skeletal or joint disease, higher number of pregnancies, parental history of ankle ulcers, physical inactivity, history of ulcers, severe lipodermatosclerosis (panniculitis that leads to skin induration or hardening, increased pigmentation, swelling, and redness), and venous reflux in deep veins.5 Poor prognostic signs for healing include ulcer duration longer than three months, ulcer length of 10 cm (3.9 in) or more, presence of lower limb arterial disease, advanced age, and elevated body mass index.6

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Arterial pulse examination and measurement of ankle-brachial index are recommended for all patients with suspected venous ulcers.1

C

Based on a clinical practice guideline on disease-oriented outcome

Color duplex ultrasonography is recommended in patients with venous ulcers to assess for venous reflux and obstruction.1

C

Based on a clinical practice guideline on disease-oriented outcome

Further evaluation with biopsy or referral to a subspecialist is warranted for venous ulcers if healing stalls or the ulcer has an atypical appearance.1,5

C

Based on a clinical practice guideline and clinical review on disease-oriented outcome

Compression therapy is beneficial for venous ulcer treatment and is the standard of care.1,28

A

Based on a clinical practice guideline on disease-oriented outcome and systematic review of moderate-quality evidence

Dressings are recommended to cover venous ulcers and promote moist wound healing. No one dressing type has been shown to be superior when used with appropriate compression therapy.1,18

C

Based on a clinical practice guideline on disease-oriented outcome and review article

Pentoxifylline is effective when used as monotherapy or with compression therapy for venous ulcers.1,19,39

A

Based on a clinical practice guideline on disease-oriented outcome, commentary, and Cochrane review of randomized controlled trials

Early endovenous ablation to correct superficial venous reflux improves ulcer healing rates.21

B

Based on one randomized controlled trial of more than 400 patients


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Arterial pulse examination and

The Authors

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SUSAN BONKEMEYER MILLAN, MD, FAAFP, FAPWHc, is medical director of the University of Florida Health Wound Care and Hyperbaric Center, and a clinical assistant professor in the Department of Community Health and Family Medicine at the University of Florida College of Medicine, Gainesville....

RUN GAN, MD, FAPWHc, is assistant medical director of Jonesville Family Medicine at the University of Florida College of Medicine. He is a staff physician at the University of Florida Health Wound Care and Hyperbaric Center and a clinical assistant professor in the Department of Community Health and Family Medicine at the University of Florida College of Medicine.

PETRA E. TOWNSEND, MD, FAPWHc, is a practicing family physician at Springhill Family Medicine at the University of Florida College of Medicine. She is a staff physician at the University of Florida Health Wound Care and Hyperbaric Center and a clinical assistant professor in the Department of Community Health and Family Medicine at the University of Florida College of Medicine.

Address correspondence to Susan Bonkemeyer Millan, MD, FAAFP, FAPWHc, UF Health Wound Care and Hyperbaric Center, 3951 NW 48th Terr., Ste. 211, Gainesville, FL 32606 (email: sbmillan@ufl.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. O'Donnell TF Jr, Passman MA, Marston WA, et al.; Society for Vascular Surgery; American Venous Forum. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg. 2014;60(2 suppl):3S–59S....

2. Ruckley CV, Evans CJ, Allan PL, et al. Chronic venous insufficiency: clinical and duplex correlations. The Edinburgh Vein Study of venous disorders in the general population. J Vasc Surg. 2002;36(3):520–525.

3. Lal BK. Venous ulcers of the lower extremity: definition, epidemiology, and economic and social burdens. Semin Vasc Surg. 2015;28(1):3–5.

4. Rabe E, Guex JJ, Puskas A, et al.; VCP Coordinators. Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program. Int Angiol. 2012;31(2):105–115.

5. Vivas A, Lev-Tov H, Kirsner RS. Venous leg ulcers. Ann Intern Med. 2016;165(3):ITC17–ITC32.

6. Meaume S, Couilliet D, Vin F. Prognostic factors for venous ulcer healing in a non-selected population of ambulatory patients. J Wound Care. 2005;14(1):31–34.

7. Reich-Schupke S, Doerler M, Wollina U, et al. Squamous cell carcinomas in chronic venous leg ulcers. Data of the German Marjolin Registry and review. J Dtsch Dermatol Ges. 2015;13(10):1006–1013.

8. Alavi A, Sibbald RG, Phillips TJ, et al. What's new: management of venous leg ulcers: treating venous leg ulcers. J Am Acad Dermatol. 2016;74(4):643–664.

9. Rice JB, Desai U, Cummings AK, et al. Burden of venous leg ulcers in the United States. J Med Econ. 2014;17(5):347–356.

10. Chi YW, Raffetto JD. Venous leg ulceration pathophysiology and evidence based treatment. Vasc Med. 2015;20(2):168–181.

11. Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014;130(4):333–346.

12. Raffetto JD. Pathophysiology of chronic venous disease and venous ulcers. Surg Clin North Am. 2018;98(2):337–347.

13. Caprini JA, Partsch H, Simman R. Venous ulcers. J Am Coll Clin Wound Spec. 2013;4(3):54–60.

14. Shanmugam VK, Angra D, Rahimi H, et al. Vasculitic and autoimmune wounds. J Vasc Surg Venous Lymphat Disord. 2017;5(2):280–292.

15. Kokkosis AA, Labropoulos N, Gasparis AP. Investigation of venous ulcers. Semin Vasc Surg. 2015;28(1):15–20.

16. Hettrick H. The science of compression therapy for chronic venous insufficiency edema. J Am Col Certif Wound Spec. 2009;1(1):20–24.

17. Dix FP, Reilly B, David MC, et al. Effect of leg elevation on healing, venous velocity and ambulatory venous pressure in venous ulceration. Phlebology. 2005;20(2):87–94.

18. Tate S, Price A, Harding K. Dressings for venous leg ulcers. BMJ. 2018;361:k1604.

19. Jull AB, Arroll B, Parag V, et al. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst Rev. 2012;(12):CD001733.

20. Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds. Wound Repair Regen. 2009;17(3):306–311.

21. Gohel MS, Heatley F, Liu X, et al.; EVRA Trial Investigators. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018;378(22):2105–2114.

22. Jankunas V, Bagdonas R, Samsanavicius D, et al. An analysis of the effectiveness of skin grafting to treat chronic venous leg ulcers. Wounds. 2007;19(5):128–137.

23. Falanga V. Wound bed preparation and the role of enzymes: a case for multiple actions of the therapeutic agents. Wounds. 2002;14(2):47–57.

24. Dumville JC, Worthy G, Bland JM, et al. Larval therapy for leg ulcers (VenUS II): randomised controlled trial. BMJ. 2009;338:b773.

25. Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009;3(2):336–344.

26. Morozov AM, Sherman RA. Survey of patients of the Tver region of Russia regarding maggots and maggot therapy [published online December 13, 2018]. Int Wound J. Accessed January 8, 2019. https://onlinelibrary.wiley.com/doi/abs/10.1111/iwj.13046

27. Mumcuoglu KY, Davidson E, Avidan A, et al. Pain related to maggot debridement therapy. J Wound Care. 2012;21(8):400, 402, 404–405.

28. Mauck KF, Asi N, Elraiyah TA, et al. Comparative systematic review and meta-analysis of compression modalities for the promotion of venous ulcer healing and reducing ulcer recurrence. J Vasc Surg. 2014;60(2 suppl):71S–90S, e1–e2.

29. Andriessen A, Apelqvist J, Mosti G, et al. Compression therapy for venous leg ulcers: risk factors for adverse events and complications, contraindications - a review of present guidelines. J Eur Acad Dermatol Venereol. 2017;31(9):1562–1568.

30. Dolibog P, Franek A, Taradaj J, et al. A comparative clinical study on five types of compression therapy in patients with venous leg ulcers. Int J Med Sci. 2013;11(1):34–43.

31. Vandongen YK, Stacey MC. Graduated compression elastic stockings reduce lipodermatosclerosis and ulcer recurrence. Phlebology. 2000;15(1):33–37.

32. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2014;(9):CD002303.

33. Kapp S, Miller C, Donohue L. The use and acceptability of devices for compression stocking application and removal. Wound Practice and Research. 2014;22(1):34–43.

34. Nelson EA, Hillman A, Thomas K. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database Syst Rev. 2014;(5):CD001899.

35. Finlayson K, Edwards H, Courtney M. Relationships between preventive activities, psychosocial factors and recurrence of venous leg ulcers: a prospective study. J Adv Nurs. 2011;67(10):2180–2190.

36. Jull A, Slark J, Parsons J. Prescribed exercise with compression vs compression alone in treating patients with venous leg ulcers: a systematic review and meta-analysis. JAMA Dermatol. 2018;154(11):1304–1311.

37. Norman G, Westby MJ, Rithalia AD, et al. Dressings and topical agents for treating venous leg ulcers. Cochrane Database Syst Rev. 2018;(6):CD012583.

38. O'Meara S, Al-Kurdi D, Ologun Y, et al. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 2014;(1):CD003557.

39. Margolis DJ. Pentoxifylline in the treatment of venous leg ulcers. Arch Dermatol. 2000;136(9):1142–1143.

40. de Oliveira Carvalho PE, Magolbo NG, De Aquino RF, et al. Oral aspirin for treating venous leg ulcers. Cochrane Database Syst Rev. 2016;(2):CD009432.

41. Layton AM, Ibbotson SH, Davies JA, et al. Randomised trial of oral aspirin for chronic venous leg ulcers. Lancet. 1994;344(8916):164–165.

42. Evangelista MT, Casintahan MF, Villafuerte LL. Simvastatin as a novel therapeutic agent for venous ulcers: a randomized, double-blind, placebo-controlled trial. Br J Dermatol. 2014;170(5):1151–1157.

43. Coleridge-Smith P, Lok C, Ramelet AA. Venous leg ulcer: a meta-analysis of adjunctive therapy with micronized purified flavonoid fraction. Eur J Vasc Endovasc Surg. 2005;30(2):198–208.

44. Martinez-Zapata MJ, Vernooij RW, Uriona Tuma SM, et al. Phlebotonics for venous insufficiency. Cochrane Database Syst Rev. 2016;(4):CD003229.

45. Bryant R, Nix D. Acute and Chronic Wounds. 3rd ed. Elsevier Mosby; 2006:162.

46. Bowler PG, Duerden BI, Armstrong DG. Wound microbiology and associated approaches to wound management. Clin Microbiol Rev. 2001;14(2):244–269.

47. Kranke P, Bennett MH, Martyn-St James M, et al. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 2015;(6):CD004123.

48. Dumville JC, Land L, Evans D, et al. Negative pressure wound therapy for treating leg ulcers. Cochrane Database Syst Rev. 2015;(7):CD011354.

49. Dowsett C, Grothier L, Henderson V, et al. Venous leg ulcer management: single use negative pressure wound therapy. Br J Community Nurs. 2013;(suppl):S6S8–10S1215.

50. Wang E, Tang R, Walsh N, et al. Topical negative pressure therapy and compression in the management of venous leg ulcers: a pilot study. Wound Practice and Research. 2017;25(1):36–40.

51. Cardinal M, Eisenbud DE, Phillips T, et al. Early healing rates and wound area measurements are reliable predictors of later complete wound closure. Wound Repair Regen. 2008;16(1):19–22.

52. Falanga V, Sabolinski M. A bilayered living skin construct (APLIGRAF) accelerates complete closure of hard-to-heal venous ulcers. Wound Repair Regen. 1999;7(4):201–207.

53. Gohel MS, Barwell JR, Taylor M, et al. Long term results of compression therapy alone vs compression plus surgery in chronic venous leg ulcers (ESCHAR): randomized controlled trial. BMJ. 2007;335(7610):83.

54. Marston W, Tang J, Kirsner RS, et al. Wound Healing Society 2015 update on guidelines for venous ulcers. Wound Repair Regen. 2016;24(1):136–144.

55. Collins L, Seraj S. Diagnosis and treatment of venous ulcers. Am Fam Physician. 2010;81(8):989–996.

 

 

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