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Pressure, venous leg, and arterial ulcers are common and costly skin conditions that affect patients in all clinical settings. Clinical features can help differentiate these ulcers. Pressure ulcers are associated with restricted mobility, poor perfusion, and compromised skin status. Venous leg ulcers (VLUs) are attributed to chronic venous hypertension resulting from venous insufficiency or obstruction. Risk factors for a first VLU include previous nonvenous leg ulcer, male sex, chronic venous hypertension, and older age. Arterial ulcers result from skin and soft tissue ischemia due to arterio-occlusive disease. They are associated with hypertension, diabetes, chronic kidney disease, and smoking. Various methods of pressure offloading have strong evidence of effectiveness in prevention of pressure ulcers. Clinical practice guidelines support the use of compression therapy in patients with previous VLUs to prevent ulcer recurrence. For patients with chronic lower extremity ulcers, a crucial step in evaluation is measurement of the ankle-brachial index, which can identify decreased perfusion and indicate the need for referral to a vascular surgeon. The likelihood of bone involvement should be determined. Skin and soft tissue infections often complicate wound care and should be addressed at each patient evaluation. Various factors can predict likelihood of wound healing.

Case 1. Mr Fearrington is an 83-year-old man with hypertension, ischemic cardiomyopathy, and malnutrition. After hospitalization for a stroke, he recently was discharged to a long-term care facility. He presents today with a stage 2 sacral ulcer that measures 3 cm × 2 cm (1.2 in × .79 in).

Prevalence and Costs

Pressure, venous leg, and arterial ulcers are common and costly skin conditions that affect patients in all clinical settings. The prevalence of lower extremity ulcers among adults in the United States is 1% to 2%.1 Approximately 70% of leg ulcers are caused by venous disease, and approximately 20% are caused by arterial insufficiency or mixed arterial or venous disease.

In 2009, the US prevalence of facility-acquired pressure ulcers was approximately 5%.2 In 2013, a European study found that the mean prevalence of pressure ulcers was 12% among patients in long-term care settings, 35.7% among patients in hospice, and 0.04% to 4.0% among patients in the community.3 In the United States, the prevalence has been shown to be highest (29.3%) in patients in the long-term acute care setting compared with patients in other settings.2

A 2011 study performed in the United Kingdom found that venous leg ulcers (VLUs) had a point prevalence of 2.9 per 10,000 patients in one city.4 The overall prevalence of VLUs has been difficult to estimate.5

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