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Key Features

Essentials of Diagnosis

  • History of varicosities, thrombophlebitis, or postphlebitic syndrome

  • Irregular ulceration, often on the medial aspect of the lower legs above the malleolus

  • Edema of the legs, hyperpigmentation, and red and scaly areas (stasis dermatitis) support the diagnosis

General Considerations

  • Patients at risk may have a history of venous insufficiency, either with obvious varicosities or with a past history of thrombophlebitis, or with immobility of the calf muscle group (paraplegics, etc)

  • Red, pruritic patches of stasis dermatitis often precede ulceration

  • Because venous insufficiency plays a role in between 75% and 90% lower leg ulceration, testing of venous competence is a required part of leg ulcer evaluation even when no changes of venous insufficiency are present

  • The left leg is usually more severely affected than the right

Clinical Findings

Symptoms and Signs

  • Classically, chronic edema is followed by a dermatitis, which is often pruritic; these changes are followed by hyperpigmentation, skin breakdown, and eventually sclerosis of the skin of the lower leg

  • The ulcer base may be clean, but it may have a yellow fibrin eschar that often requires surgical debridement

  • Ulceration is often on the medial aspect of the lower legs above the malleolus

  • Edema of the legs, varicosities, hyperpigmentation, and red and scaly areas (stasis dermatitis) and scars from old ulcers support the diagnosis

  • Ulcers that appear on the feet, toes, or above the knees are atypical for venous stasis—consider other diagnoses

Differential Diagnosis

  • Arterial insufficiency (arterial ulcer)

  • Bacterial pyoderma (eg, infected wound or bite)

  • Trauma

  • Diabetic ulcer

  • Pressure injury (formerly pressure ulcer)

  • Vasculitis

  • Pyoderma gangrenosum

  • Skin cancer

  • Infection (eg, mycobacterial, fungal, tertiary syphilis, leishmaniasis, amebiasis)

  • Sickle cell anemia

  • Embolic disease (including cholesterol emboli)

  • Cryoglobulinemia

  • Calciphylaxis

Diagnosis

Laboratory Tests

  • Thorough evaluation of the patient's vascular system (including measurement of the ankle-brachial index [ABI]) is essential

Imaging Studies

  • Doppler examination is usually sufficient (except in the diabetic patient) to evaluate venous competence

Diagnostic Procedures

  • A punch biopsy from the border (not base) of the lesion may be helpful

Treatment

Medications

Cleaning of the ulcer

  • The patient is instructed to clean the base with saline or cleansers such as Saf-clens daily

  • Once the base is clean

    • The ulcer is treated with metronidazole 1% gel to reduce bacterial growth and odor

    • Any red dermatitic skin is treated with a medium- to high-potency corticosteroid ointment, such as triamcinolone acetonide 0.1% ointment

    • The ulcer is then covered with an occlusive hydroactive dressing (Duoderm or Cutinova) or a polyurethane foam (Allevyn) followed by an Unna zinc paste boot, changed weekly

    • If the patient is diabetic, becaplermin ...

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