Venous Stasis Ulcers

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)

• 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

• 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

• 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

• 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

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

  • Silver impregnated dressings may aid in healing

  • 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 ...