written by Sara Jaen of ebjuris.com

About venous ulcers

With rampant obesity on the rise around the world, don’t be surprised to find more cases of venous ulcers, aka venous insufficiency (stasis) on the rise. Most commonly identified in patients suffering from heart failure, diabetes or obesity, venous ulcers are chronic skin and subcutaneous lesions that are typically found on the lower extremities between the calf and the ankle, where perforator veins are located and tends to be more common in older people, though such statistics may change over time. Venous ulcers are the most common type of leg ulceration, and typically occur more often in elderly females than males, and the long-term healing prognosis is less promising than ulcers caused by arterial damage or diabetic ulcers. Those suffering from deep vein thrombosis may also increase the risk for venous ulcers, as does a family history of varicose veins and reverse blood flow. In addition, smoking, excessive alcohol use, lack of exercise and poor nutrition all offer contributing factors to increase the risk of developing venous leg ulcers.

While these ulcers used to be known as “venous stasis”, due to the belief that their development was caused by blood pooling in veins of the legs, it is now known that such pooling is caused by venous reflux. Because venous valves are not working properly, blood backs up into superficial veins, which increases venous pressure that elongates and dilates those veins. Since tissues surrounding such sites do not receive adequate supplies of oxygen, nor white blood cells, toxins build and may eventually cause ulcers. Leg veins are equipped with valves that help to insure that blood flows in one direction, toward the heart, especially while standing and sitting down. These important veins are located deep within the muscle tissue of the leg, whose contractions squeeze these veins and help drive blood back toward the heart. However, when one of these veins or valves is damaged, the muscularly driven blood flow action fails and blood pools in the leg muscles while standing or sitting, which serves to drastically increase the pressure in venous walls and surrounding tissues. It may take years for such damage to accrue, and once it does, a venous ulcer might result.

Venous ulcers most commonly present on the medial aspect of the lower leg and ankle regions, superior to the basic lower leg, bilaterally. Three major types of lower extremity ulcers are the most common: venous (stasis), peripheral neuropathy/diabetic and arterial. It’s important that medical staff be able to differentiate between them in order to promote proper care and prevention. Arterial ulcers often occur as a result of arterial occlusive disease that results in tissue necrosis, caused by blockage of arterial flow. Peripheral neuropathic ulcers usually present in the foot and are most commonly caused by damage to peripheral circulation.

Venous ulcers however, are open lesions on the surface of the skin and subcutaneous tissue of lower leg areas, found most often between the calf and ankle joint. Because valves in lower leg veins have become damaged, blood flow sometimes backs up into veins. Because of this, circulation slows and fluids seep out of overflowing veins and into surrounding tissues, which leads to tissue breakdown, edema and ulcers. Such ulcers can take years to develop, and then flare up on and off for some time. Once an ulcer has developed, it may be extremely difficult to heal. Those who are overweight, those with decreased mobility or those previously diagnosed with deep vein thrombosis, phlebitis, chronic heart failure, as well as those who have suffered trauma to the lower extremity, either by accident, surgery or orthopedic procedures, may be prone to the development of venous ulcers.

Symptoms

Signs and symptoms of venous ulcers may initially present as a deep, aching throb in the lower limb, accompanied by a ‘heavy feeling’ and edema that grows worse as the day progresses. Some symptoms may be relieved and comfort attained by elevating the feet or legs at the end of the day, so it may take months, even years, for damage to accrue to the point where ulcerations appear on the surface of the skin. Venous disease is diagnosed by class, and can range from varicose veins to edema without skin changes, to skin changes with ulcerations.

Early indications or signs that a venous ulcer may be presenting are first indicated by the appearance of darkened red or purple skin over the affected site. This discoloration is accompanied by itching, dry and thickening skin. At this stage, it is possible to prevent an ulcer from developing, but knowing and responding to the signs is important and many people try to treat the condition themselves at this point, not realizing the problem.

For most people, the diagnosis of a venous ulcer is obtained through a physical exam, though some physicians also request a Doppler ultrasound to determine the extent of venous damage in the lower extremities. At its most basic, treatments for venous ulcers are focused on improving blood circulation in the legs. For some, more aggressive treatments such as skin grafting and vein surgery are indicated, which may take six months or longer to obtain results. Skin grafting is an effective treatment for stubborn healing ulcers, while vein surgery, while it won’t improve healing, does help to prevent recurring venous ulcers.

Newer studies in the treatment of venous ulcers has shown that growth injections, such as the G-M CSF factor, or granulocyte-macrophage colony stimulating factor increases the healing process, as do injections of mesoglycan, combined with use of compression bandages for six months, also facilitates the healing process.

Venous ulcers often develop in the lower extremities of people who are overweight or who have been working on their feet throughout much of their careers. Typical signs of venous insufficiency include edema in the foot and lower extremity as well as varicose veins and hyperpigmentation of the skin surrounding the ankle joint. Ninety-five percent of venous ulcers develop in what is commonly known as the ‘gaiter area’, on the lower leg just above the ankle. While venous ulcers can affect any portion of the lower limb, may also cause induration, marked by loss of elasticity and pliability, as well as dilated superficial veins, various forms of dermatitis and even intense itching and weeping of the lower leg.

In cases where treatment has not been begun, lipodermatosclerosis may develop. The skin takes on a woody, stiff appearance similar to a pickled affect, and may be prone to ulcerations and infections. On many occasions, lipodermatosclerosis is misdiagnosed as cellulites. For many, these symptoms also accompany nightly leg cramps, coupled with the appearance of spider veins. In some suffering from venous ulcers, thrombophlebitis aggravates the condition and causes collateral damage in surrounding veins. The increase of venous pressure serves to impede flow in the capillaries, resulting in red blood cell leakage into interstitial tissues. Such conditions result in tissue damage and eventually, ulceration.

Appearance

A venous ulcer presents in stages that can grow increasingly alarming if not promptly treated. Discoloration of the affected area may appear ruddy at first, though the skin may take on a brownish-reddish hue. In light skinned patients, the skin may appear purpler, or deeply tanned, while in darker skinned patients; the skin may appear dark purple, brown or black. Varicose veins are also often visible, though the remainders of the foot and heel areas usually maintain a normal appearance. While the depth of most venous ulcers is fairly shallow, they can grow deeper if left untreated. Wound edges are mostly irregular and can widen over a rather quick period of time. The ulcer bed itself is often covered with a yellowish fibrinous or reddish, granulated appearing tissue. The affected area may weep in moderation or increase to heavy saturation and the skin temperature can range from normal to warm to the tough. Pitting and non-pitting, as well as edema can occur, as well as cellulites and induration. Granulation is frequently present during healing, though infection is less common.

Treatment

Venous ulcers can be extremely difficult to treat, as they are stubborn to heal. The longer venous ulcers are left untreated, the more damage is done to skin tissues surround the ulcer. Initially, many people attempt to care for venous ulcers themselves, though an interdisciplinary approach to the successful treatment of venous ulcers involves dermatologists, well-trained nurses, dietary interventions to promote wound healing, especially with foods rich in Vitamins A, C and Zinc. When necessary, vascular and plastic surgeons are able to provide optimal healing with a decreased chance of recurrence.

In most cases, those who have suffered from a venous ulcer less than a year nearly always heal completely, though older ulcers may never completely close. Depending on the size of the ulcer when treatment begins, the effective use of compression bandages and the treatment of underlying venous conditions all have determining factors in the length of time it may take for a venous ulcer to heal. In severe cases, skin grafting may be necessary to facilitate recovery. Some venous ulcers heal in a matter of days, while others never completely heal. Several treatments are possible with venous ulcers, but the most common, and useful, especially during the early stages of the condition, are compression stockings. Compression stockings aid wound healing while at the same time reducing venous dermatitis and improves circulation within the extremity.

Keeping the ulcerated area clean and properly dresses can prevent infection and serves to promote healing. Elevating the affected leg for as long as possible prevents blood from pooling in the affected area and also enables veins and tissues to begin healing. However,
venous ulcers are prime targets for bacterial infection, whose signs include, but are not limited to tenderness and pain accompanied by odor emanating from the wound itself, and changes in wound color, most commonly green or black. Failure to heal is a prime indication that a venous ulcer has become infected and tissue samples should be collected for testing.

Many venous ulcer wounds are treated with moist wound-healing methods. Topical treatments provide moist environments that promote healing, while at the same time decreasing chances of infection. Antibiotics are only prescribed when signs of infection are present, as they do not improve ulcer healing, but eradicate infection in surrounding tissues. At the same time, care must be taken to limit the use of such ointments for long periods of time to prevent bacterial resistance and sensitization of surrounding tissues. Oral antibiotics should be used for at least ten days, when possible, though broad-spectrum antibiotics should be avoided to prevent the development of resistant strains of bacteria. Both creams and dressings may be combined with compression therapies to stimulate blood flow through superficial veins to deeper ones. Maintaining a moist wound environments and debridement of dead tissues will increase the healing rate and offer a reduction in pain to most patients.

For more severe cases, surgical debridement is called for, which removes infected and dead tissue as well stimulates wound healing. If warranted, wound-VAC therapy also serves to help heal stubborn wounds and drains excess fluid from the wound site while at the same time, applying negative pressure in the wound bed. Both oral and IV antibiotics may also be used in conjunction with topical treatments.

In some cases, the age of the patient, their mobility factors and the presence of lipodermatosclerosis and deep venous conditions often have much to do with whether or not the patient is at risk for poor healing.

Following the venous ulcer healing process, patients are encouraged to continue wearing compression stockings, as a repeat occurrence is likely if measures are not taken to prevent further episodes. However, compression stockings are expensive, and many patients don’t feel they can afford them. Wearing them correctly is also an issue, especially in older patients, as is the difficulty of washing them so as to retain their effectiveness. Such stockings are extremely difficult to apply, and many older patients don’t have the hand or limb strength to apply them correctly. In many patients, venous ulcers recur. These ulcers can erupt in the same place, or in a different location, which is why it is vital that treatment for venous ulcers continues even after the ulceration is healed, especially for those patients with underlying venous flow issues. Long-term use of compression stockings is still considered the best way to prevent recurring ulcers.

While venous ulcers are the result of various causes, early treatment is imperative to successful healing measures, which can be accomplished with a multi-directional approach that includes nutrition, proper positioning, exercise, medications, teaching and various methods to prevent or decrease edema, pain and further damage to already fragile tissues.