Leg Ulcers

A leg ulcer is defined as ‘the loss of skin below the knee on the leg/foot, which takes more than 6 weeks to heal’

Venous leg ulceration is due to sustained venous hypertension, resulting from chronic venous insufficiency and/or impaired calf muscle pump.

Venous Ulcer

Background

• Common, chronic, recurring
  • Account for 85% of leg ulcers; around 1-3/1000; incidence rises with age (rare below 45)

Pathophysiology

• Usually a result of venous insufficiency caused by venous valve dysfunction in the lower limbs, particularly of perforating veins.
• When the leg muscle contracts, instead of the blood being pushed towards the heart, it can get pushed backward and out of the vein if pressure is great enough.
• This causes oedema, venous eczema and ulceration

Aetiology/Risk Factors

• Modifiable
  • Obesity
  • Immobility
  • Smoking
• Unmodifiable
  • Immobility
  • Personal/family history of varicose veins or venous insufficiency
  • Age
  • DVT history
  • Hx of trauma

Presentation

• Usually large, shallow, painless and situated around the medial or lateral malleoli or in the ‘gaiter’ region of the leg
  • May be associated with varicose veins (examine lying and standing), venous eczema, haemosiderin pigmentation, atrophie blanche (smooth, white plaques stippled with telangiectasia) and venous flare
  • Look for other signs of venous insufficiency e.g. oedema; lipodermatosclerosis (rigid, woody hard fibrosis of the skin/subcut tissues causing the leg to resemble an ‘inverted champagne bottle’)
• Exclude arterial disease
  • Hair loss, cold, pulseless, pale, poor cap refill (NB arterial ulcers are often painful and deeper)
• Also consider neuropathic ulcers as part of the DDx (painless, deep, usually found on the heel/MTP head/big toe)

Investigations

• Doppler studies and ABPI to exclude arterial insuffiency (ABPI <0.8)
• Swabs
• Other investigations may be appropriate e.g. FBC (anaemia; leucocytosis); glucose; autoantibodies (vasculitic ulcer) etc

When to refer

• Suspected malignant ulcer; peripheral arterial disease; diabetes; rheumotoid ulcer/vasculitic ulcer; atypical distribution; suspected contact dermatitis (either as a primary cause or secondary to treatment); non-healing ulcer

Management

• Uncomplicated (non infected; non persistent)
  • Wash (irrigate and remove slough, necrotic tissue, excess granulation/fibrous tissue) with warm tap water, saline or potassium permanganate solution (latter if malodourous)
  • Dress the wound with a low-adherent dressing (specialist dressings e.g. hydrogels/alginates may be useful for excess slough or exudate (respectively))
  • Compression bandaging
    • 4/3-layer if immobile and 2-layer if mobile
    • NB Contraindicated if ABPI <0.8
    • Change once a week
  • Foot elevation (do NOT prescribe diuretics for oedema)
  • Assess for symptom persistence, development of cellulitis or worsening eczema
  • Pentoxyphilline can be considered to improve healing (specialist use)
• If the ulcer appears infected, consider swabbing
  • Only prescribe antibiotics if the culture is positive
• If the surrounding ‘norma’ skin becomes infected (hot, red, painful), consider flucloxacillin or referral for IV antibiotics
• After the ulcer has healed, the use of compression stockings is recommended to prevent recurrence
• If there is no improvement after 3 months, consider referral for further investigation and management

Complications

• Immobility
• Infection
• Negative impact on QoL and daily function e.g. social isolation, loss of independence etc
• Osteomyelitis
• Septicaemia

Arterial Ulcers

Aetiology/Risk factors

• Coronary heart disease; stroke/TIA; peripheral vascular disease
• Diabetes mellitus
• Obesity/immobility
• Hypertension
• Smoking
• Age

Presentation

• Often more distal e.g. dorsum of the foot or toes (compared with venous ulcers); usually painful, particularly with leg elevation (e.g. nocturnal)
  • Classic ‘punched out’ appearance with clear edges
  • The base of the ulcer is classically blue/gray (granulation tissue)
  • Commonly associated with features of peripheral arterial disease e.g. hairless, cold, pale, pulseless
• May have features of other arterial disease e.g. hypertension

Investigations

• ABPI (usually <0.8) and Doppler studies
• Angiography

Management

• Similar to peripheral arterial disease– may require surgery
• Concentrate of lowering cardiovascular risk i.e. smoking cessation; weight loss; lipid control;

Neuropathic Ulcers (usually diabetic)

• Often appear as painless, deep ulcers in the ball of the foot or heel as a result of repeated trauma to the foot