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Ulcers caused by venous insufficiency are the most common type of leg ulcerations, accounting for 70% to 80%. They are sometimes called stasis ulcers. About 10% to 20% of leg ulcerations have a mixed venous and arterial etiology. Leg ulcers caused by chronic venous insufficiency lead to significant morbidity and can have a long-term negative impact on an individual's quality of life. Diagnosis can be difficult, and management is often expensive and labor-intensive.
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Venous ulcers most commonly arise secondary to varicose veins or postphlebitic syndrome. They may also be seen in patients with a history of a deep vein thrombosis (DVT), obesity, or previous leg injury or surgery. When a patient with normal venous return stands or walks, the calf muscle acts in concert with veins and associated valves to empty the venous system and reduce its pressure.3 Venous hypertension develops when the valves become incompetent. This leads to tissue hypoxia and ultimately to skin destruction and breakdown. In addition, wound healing processes are compromised and autolytic processes take action. The result is loss of the epidermis and dermis and the formation of an ulcer.
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Clinical Presentation
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Most commonly, patients complain of a heavy or swollen feeling in the affected leg. Pain ranges from mild with a superficial ulceration to severe with a deep ulceration. Patients may describe limitation of movement of the affected extremity, depending on the location of the ulcer. In addition, patients with venous stasis and dermatitis may have significant pruritus of the skin surrounding an ulcer.
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Most patients with venous ulceration have some degree of nonpitting or pitting edema. Varicosities may be visible, and there is often hyperpigmentation from hemosiderin deposition over the shin. Typically, venous ulcers occur over or proximal to the medial malleolus, but they may occur anywhere below the knee. They can be single or multiple, small or large, shallow or deep. They are usually well marginated with sloped borders, but can present with irregular shapes (Figure 29-1). Often, there is fibrinoid material and/or granulation tissue at the base. The surrounding skin may have an inflamed, eczematous appearance. These ulcers can sometimes have copious drainage.
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There are no specific laboratory findings that point toward a diagnosis of venous ulceration. However, a complete blood count (CBC), erythrocyte sedimentation count (ESR), and blood glucose can help to diagnose an underlying hematologic, inflammatory, or diabetic condition. A culture will likely yield mixed flora, and may not be relevant unless the wound appears clinically infected. A venous Doppler ultrasound can help to locate venous occlusion or incompetent perforating veins.
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Diagnosis and Differential Diagnosis
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The key diagnostic findings of venous ulcers are well-circumscribed ulcerations usually over the shin or medial malleolus, on a backdrop of hyperpigmentation, varicosities, and lower extremity edema. Pedal pulses are usually present. Fibrinoid material or granulation tissue is often observed at the base of the ulcer.
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See Table 29-1 for the differential diagnosis of leg ulcers.
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One must always know the cause of an ulcer before designing a treatment plan. In treating venous ulcers, the primary goal is to reverse venous hypertension so that there is an environment amenable to wound healing.4 The most effective way to accomplish this is with compression, the gold standard for the treatment of venous leg ulcers. Compression reverses venous hypertension, has positive effects on microcirculation, reduces deep venous reflux, reduces lower leg edema, and allows for improved oxygenation of the skin. There are two categories of compression products available: inelastic compression products, which are used for reduction of edema and healing of ulcers, and elastic compression products, which are used for maintenance to prevent ulcer recurrence. The most widely used inelastic products are Unna boots or Profore boots. These are occlusive wraps that are applied as an ace wrap would be applied in the office and removed 1 week later. They may also be applied at the patient's residence by a trained home health professional. An important companion to the use of these leg wraps is frequent elevation of the legs. Elastic compression is achieved with products such as TEDS or Jobst stockings, which can be worn on a regular basis for maintenance, once a venous ulcer has healed. Compression should always be a component of treating a venous ulcer, but one must rule out the possibility of arterial insufficiency prior to applying a compressive dressing to a patient.
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In addition to compression, the treatment of the wound itself is very important. The ulcer bed must be prepared so as to allow for optimum healing.5 Tissue removal or debridement may be necessary, as the fibrinoid material present in some wounds interferes with healing. This may be accomplished surgically or mechanically with scissors, a curette, or a scalpel, and may require local anesthesia. Enzymatic or proteolytic agents (eg, Santyl, Panafil, or Accuzyme) can also be used to more slowly debride a wound when necessary.
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The moisture balance in an ulcer can have a significant effect on healing. In particular, wounds heal more quickly in a moist environment. This is accomplished by using dressings that absorb excess fluid in a very exudative wound, or that retain fluid in an otherwise dry wound.6 When there is significant exudate, some appropriate absorptive dressing choices are Kerlix, gauze sponges, surgical pads, hydrophilic foam dressings (eg, COPA), or hydrocellular polyurethane dressings (eg, Allevyn). When a wound is dry, some appropriate dressing choices are Telfa, Vaseline petroleum gauze, or a nonadhering oil emulsion dressing (eg, Curity).
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An ulcer often needs help with reepithelialization. There are several products that aid in providing contact between the wound edges so that they are stimulated to grow back together. Hydrocolloid dressings (eg, Duoderm or Restore) provide this function. Extracellular matrix dressings (eg, Oasis, or Matristem) create a scaffold over which growth factors and keratinocytes can migrate, thus bringing a wound together. Biologic agents (eg, Apligraf or Dermagraft) provide the building blocks for new skin to regenerate.
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One last item to be addressed in the treatment of a venous ulcer is the possibility of infection. Most ulcers are colonized with bacteria, but this is not often to the level of actual infection. These ulcers do not require antibiotic treatment. Certainly, if there are clinical signs of infection such as thick odorous exudate, surrounding erythema, or increasing pain, one should consider the use of an oral antibiotic after a culture has been taken. If a patient has stasis dermatitis adjacent to an ulcer, this should be treated with a midpotency topical steroid, such as triamcinolone ointment, 0.1%. The latter will help to maintain the integrity of the skin, thus decreasing the risk of cellulitis.
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Ongoing treatment may be necessary for many months before a venous ulcer will heal. Recurrence is common, seen in 54% to 78% of all venous ulcers.7
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Indications for Consultation
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If the underlying etiology of a leg ulcer cannot be determined, a specialist such as a vascular surgeon or a dermatologist should be consulted. If an ulcer is not healing despite appropriate treatment, referral to a wound care clinic should be considered. Also consider referral if the necessary management products are not available at the patient's primary clinic.