Because of the increasing obesity and longevity of the U.S. population, the incidence of chronic venous insufficiency and venous stasis ulcers is sure to rise. Weingarten reviews state-of-the-art management of these ulcers.
Venous stasis disease most commonly occurs in patients with obesity, congestive heart failure or diabetes. Ulcers often begin during the working years, adding lost productivity costs to the already substantial direct medical costs of treating this disease. The typical signs of chronic venous insufficiency include pedal edema, varicose veins and skin hyperpigmentation. Stasis ulcers most commonly occur at the medial malleolus, but any part of the lower limb can be involved. Patients with stasis ulcers typically note pain at the ulcer site and heaviness in the limb caused by edema.
Within the differential diagnosis of leg ulcers related to venous stasis are less common ulcers resulting from arterial insufficiency, vasculitic disease or skin malignancy. Noninvasive measurement of arterial function by use of a blood pressure cuff and Doppler probe to assess the ankle-brachial index is an effective method of screening for arterial insufficiency. Biopsy of any nonhealing ulcer can guide the physician in the choice of antibiotic (if necessary) and exclude the possibility of vasculitis or skin malignancy.
Diuretics are commonly used in the treatment of venous insufficiency but are generally ineffective without the concomitant use of compressive dressings. Antibiotic use should be based on tissue culture of the wound. The most important intervention is effective compression of the edematous limb. The Unna boot, when properly applied (maximum pressure at the ankle, graduating to no compression at the top of the boot), is a time-honored treatment but cannot be used if there is a large amount of wound drainage. Various types of compressive stockings are also available. Knee-high stockings are better tolerated by patients than thigh-high styles. Intermittent pneumatic compression pumps may be used as adjunctive therapy.
Maintenance of a moist wound microenvironment and debridement of necrotic tissue increase wound healing rates and reduce pain. Moist, occlusive dressings (e.g., hydrocolloid gels) also decrease ulcer pain. Prolonged use of topical antiseptic agents (povidone-iodine, hydrogen peroxide, acetic acid) should be avoided.
Newer technologies for management of venous stasis ulcers follow those used in the care of diabetic ulcers. Topically applied compounds containing various growth factors have been helpful in some studies. Ligation of refluxing veins near the ulcer site or split-thickness skin grafting has been used in the most refractory cases.