Chronic leg ulcer is an open lesion between the knee and ankle joint that remains unhealed for at least 4 weeks
Aetiology
60-80% venous - due to venous blood stasis
22% arterial - manifestation of peripheral vascular disease
5% diabetic - diabetes impedes the normal stages of wound healing
Other rare causes include autoimmune vasculitis (e.g. associated with rheumatoid arthritis, SLE), tropical disease and TB
Often multifactorial
Prevalence increases with age
Pathophysiology
Arterial ulcers
Caused by insufficient blood supply due to peripheral vascular disease
Venous ulcers
Elevation of venous pressure in the legs e.g. by abdominal obesity which resists venous return from the legs
Veins dilate and valves become incompetent, varicose veins develop
The increased hydrostatic pressure in the vessels results in red blood cell leakage into the tissue resulting in swelling, haemosiderin, pigmentation and inflammation (due to breakdown products) i.e. venous (stasis) dermatitis
The skin cannot heal well due to poor blood supply, so begins to break down
Venous insufficiency also acts as a risk factor for DVT/PE
Clinical presentation
Clinical features of venous ulcers
Most venous ulcers (87%) occur in the gaiter area
Ulcers are shallow, exudative and warm
Other signs of venous insufficiency may be present such as ankle swelling, varicose veins, haemosiderin deposition, venous eczema and lipodermatosclerosis
Clinical features of arterial ulcers
Arterial ulcerations tend to affect the foot
The ulcers usually have a punched-out appearance
The ulcer and the surrounding skin are cold, white and shiny
Other signs of peripheral arterial disease may be present such as intermittent claudication
Pain may also occur at rest, usually at night when the legs are elevated and this is relieved by hanging feet off the end of the bed
Peripheral pulses may be absent
Investigations
Assessment of ulcer - record position and measure surface area
ABPI - establish if there is arterial disease
Wound swab - only if ulcer increasingly painful/exudate/malodour/enlarging
Bloods - FBC, LFTs, U+Es, CRP
Patch testing - to ulcer treatments e.g. bandages, dressings, creams
Duplex scan if indicated to rule out arterial disease
Management
Arterial ulcers
Management is by reducing modifiable risk factors - treat hypertension, prescribe statin, prescribe antiplatelet
Venous ulcers
Aim to heal simple venous ulcers by 12 weeks
Control pain
De-sloughing agent if necessary
4 layer compression bandaging - may need to increase compression gradually if pain a problem
Leg elevation
Other options for difficult wounds - wound bed preparation
Autolytic - the use of dressings to create moist wound environment and hydrate necrotic tissue or eschar (hydrogen, honey)
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