Venous Insufficiency and Leg Ulcers

A long term chronic and recurring condition. Assessment of foot pulses and ankle brachial pressure index as is useful to determine suitability for compression therapy.

About

• Venous ulcerations are the most common type of ulcer affecting the lower extremities.

Aetiology

• Venous leg ulcers can develop after a minor injury
• Venous ulcers are secondary to venous stasis
• There is chronic stretching vessel of the superficial veins walls.
• Due to improper functioning of venous valves, usually of the legs
• These eventually become thinner and ulcerate.

Risks

• Increasing age, Previous DVT
• Obesity, Lower limb fracture, surgery or injury
• Immobility, HTN, Prolonged upright posture
• Multiple previous pregnancies, Varicose veins
• Avoid steroids. Nicorandil has been associated with ulcers

Clinical

• Chronic full-thickness skin loss on the lower leg
• Shallow, medial, superficial often with exudate
• Chronic brownish discolouration, Dermatitis, Thick toenails

Differentials

• Traumatic or arterial ulceration
• Pyoderma gangrenosum

Investigations

• FBC, U&E: Dehydration may impair healing
• ESR/CRP - may suggest infection of elevated
• Albumin: low suggests protein loss and malnutrition, which may delay healing.
• Check Doppler's and ABPI (ankle-brachial pulse index) prior to compression.
• HbA1c: to assess for diabetes mellitus.
• Duplex USS can confirm venous obstruction or valve incompetence
• Bacteriological swabs should only be taken where there is clinical evidence of infection

Management

• Manage any oedema and infection. Keeping wounds clean. Weight reduction. Elevated leg above heart height when possible.
• Only effective treatment is to compress the superficial venous using a four-layer compression bandage. Compression (eg, four-layer elastic bandaging) helps heal venous ulcers, limits leg swelling and provides symptomatic relief. Compressive dressings or devices should not be applied if the arterial circulation is impaired.
• Debridement is used to remove dead tissue along the borders of the wound and excessive slough from the wound bed.
• Skin grafting may be required for stable, uninfected, large venous ulcers that have not shown improvement with other measures.

References

• Superb NZ dermatology site on Venous Ulcers