Introduction
Venous ulcers are a common problem that can cause significant disability requiring prolonged wound care, hospitalisation and have a high rate of recurrence.
They are more common in the elderly, especially in patients with a history of DVT or varicose veins. Ulceration develops in damaged skin in the lower leg region (gaiter). Venous ulcers also occur in patient with poor mobility who sit with their legs dependent for long periods of time.
Causes
The main issue with venous ulcer is the development of too much pressure in the leg veins. This increased pressure allows inflammatory white blood cells to leak from the veins into the tissues of the lower leg. This in turn damages the skin and subcutaneous tissue, leading to a brown pigmentation, fibrosis and scarring of the tissues and subsequent ulcer formation. Usually, minor trauma is the last straw, and once the skin is damaged fluid tends to leak through the wound, which has a high risk of infection, causing more tissue damage and an increase in size of the ulcers.
Increased pressure can occur for a number of reasons:
- Varicose veins.
- Deep venous incompetence (following DVT).
- Poor mobility / leg dependency.
- Normal walking activates the calf muscle that helps to pump blood through the veins. If walking is limited or not possible then the lack of calf muscle pumping will increase pressure in the veins and contribute to ulcer formation.
Symptoms
The main symptom is large ulcers. They are often very extensive, leak a lot of oedema fluid, and frequently become infected. They may be painless, but often become painful when they are infected. They require often quite complex dressings and frequently result in hospitalisation to manage infection and wound care.
Tests
The main investigations aim to identify the cause of the ulcer, exclude any contributing factors and allow appropriate treatment to commence.
Wound swabs to identify infection are important to guide antibiotic therapy.
Ultrasound is used to assess the function of both the deep and superficial leg veins. USS is also used to check on the arterial blood supply as this will exacerbate the ulcer and contribute to poor wound healing.
Long standing ulcers (>3 months) should be biopsied to exclude malignancy as skin cancers can ulcerate and have s similar appearance.
Diagnosis
Diagnosis is based on clinical suspicion and then confirmed with the relevant investigations.
Treatment
Venous ulcers require a multi-disciplined approach to management.
- Wound care is a critical component.
- Venous ulcers tend to leak significant volumes of fluid, making dressing choice difficult.
- Infection control.
- Appropriate antibiotics and topical antiseptic agents to control secondary infection.
- Compression.
- The fundamental cause of venous ulcers is increased pressure within the leg veins. Compression stockings are a critical component of management.
- Elevation.
- To help reduce venous pressure elevation of the feet (above the heart level) to try and reduce swelling.
- Surgical intervention.
- Wound debridement – usually managed with dressings but may be necessary in severe cases.
- Treatment of venous Incompetence.
- Similar options as for varicose veins.
- Skin grafting may help to reduce the size of very large ulcers.
Related Information
Varicose Veins
Deep Venous Thrombosis
Endovenous Ablation of Varicose Veins
Sclerotherapy
Vein Stripping