Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 6-52 Leg Ulcers Secondary to Venous Insufficiency + Key Features Download Section PDF Listen +++ +++ 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, family history, varicosities, obesity, or genetic diseases that predispose to venous insufficiency The left leg is usually more severely affected than the right + Clinical Findings Download Section PDF Listen +++ +++ 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 Red, pruritic patches of stasis dermatitis often precede ulceration 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 Download Section PDF Listen +++ +++ Laboratory Tests ++ Because venous insufficiency plays a role in 75% to 90% of lower leg ulcerations, testing of venous competence is a required part of a leg ulcer evaluation even when no changes of venous insufficiency are present Arterial insufficiency may coexist with venous disease; an ankle-brachial index (ABI) < 0.7 indicates the presence of significant arterial disease +++ 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 Download Section PDF Listen +++ +++ 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 has no history of skin cancer in the area, becaplermin (Regranex) may be applied to ulcers that are not becoming smaller or developing a granulating base +++ Systemic therapy ++ Pentoxifylline, 400 mg three times daily orally, administered with compression accelerates healing Zinc supplementation is occasionally beneficial in patients with low serum zinc levels If cellulitis accompanies the ulcer, oral antibiotics are recommended Dicloxacillin, 250 mg four times a day Levofloxacin, 500 mg once daily for 1–2 weeks +++ Surgery ++ Patients with an ABI below 0.5 and/or with refractory ulcerations should be considered for surgical procedure (artery-opening procedures or ablation of the incompetent superficial vein) A curette or small scissors can be used to remove the yellow fibrin eschar, under local anesthesia if the areas are very tender Grafting for severe or nonhealing ulcers Full- or split-thickness grafts often do not take, and pinch grafts (small shaves of skin laid onto the bed) may be more effective Cultured epidermal cell grafts may accelerate wound healing, but they are very expensive + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Combination of limited debridement, compression dressings or stockings, and moist dressings will heal the majority of venous stasis ulcers within months (average 18 months) Topical growth factors, antibiotics, debriding agents, and xenografts and autografts can be considered in recalcitrant cases, but they are usually not required in most patients If the ABI is < 0.5, the prognosis for healing is poor Ongoing control of edema is essential to prevent recurrent ulceration +++ Prevention ++ Compression stockings to reduce edema Compression should achieve a pressure of 30 mm Hg below the knee and 40 mm Hg at the ankle The stockings should not be used in patients with arterial insufficiency and an ABI < 0.7 Pneumatic sequential compression devices may be of great benefit +++ When to Refer ++ When ABI is < 0.7, refer patient to vascular surgeon + References Download Section PDF Listen +++ + +Attaran RR et al. Compression therapy for venous disease. Phlebology. 2017 Mar;32(2):81–8. [PubMed: 26908640] + +Couch KS et al. The international consolidated venous ulcer guideline update 2015: process improvement, evidence analysis, and future goals. Ostomy Wound Manage. 2017 May;63(5):42–6. [PubMed: 28570248] + +Gould LJ et al. Modalities to treat venous ulcers: compression, surgery, and bioengineered tissue. Plast Reconstr Surg. 2016 Sep;138(3 Suppl):199S–208S. [PubMed: 27556762] + +Khoobyari S et al. Utility of skin biopsy and culture in the diagnosis and classification of chronic ulcers: a single-institution, retrospective study. Am J Dermatopathol. 2019 May;41(5):343–6. [PubMed: 30461422] + +Neumann HA et al. Evidence-based (S3) guidelines for diagnostics and treatment of venous leg ulcers. J Eur Acad Dermatol Venereol. 2016 Nov;30(11):1843–75. [PubMed: 27558268] + +Raffetto JD. Pathophysiology of chronic venous disease and venous ulcers. Surg Clin North Am. 2018 Apr;98(2):337–47. [PubMed: 29502775] + +Sundaresan S et al. Stasis dermatitis: pathophysiology, evaluation, and management. Am J Clin Dermatol. 2017 Jun;18(3):383–90. [PubMed: 28063094]