Venous Stasis Ulcers

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

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

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

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

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