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Venous ulcers
Venous ulcers

Venous ulcers

Venous ulcers occur as a result of venous insufficiency. They are the most common type of leg ulcer and are prone to infection and often present with associated cellulitis.

Pathophysiology

The pathophysiology is not well understood at this point. It is theorised to be that valve incompetence/venous outflow obstruction impairs venous return → venous hypertension → trapping of WBCs which form a fibrin cuff, thus hindering oxygenation of the tissue + they release inflammatory mediators that cause tissue injury, poor healing and necrosis.

😷 Presentation

  • ⭐️ Painful ulcers - found mainly over the gaiter area (between top of foot and the bottom of the calf). More often found on the medial side.
  • Oedema
  • Hyperpigmentation
  • Lipodermatosclerosis - hardening of the skin due to inflammation of subcutaneous tissue.
  • Varicose eczema - itchy, flaky, red skin that occurs in people with varicose veins.
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☝🏼
These ulcers are often located over the medial malleolus. They are irregular in shape and have granulation tissue at the base. They are particularly worse at the end of the day. They may get better when lifting the leg and worse when lowering it. They are more superficial but larger than arterial ulcers.

⚠️ Risk factors

  • Increasing age
  • Venous incompetence & varicose veins
  • Pregnancy
  • Obesity
  • Physical inactivity
  • Severe leg trauma

🔍 Investigations

Diagnosis is generally made clinically.

→ Duplex Ultrasound may confirm diagnosis of venous insufficiency. This is most-commonly found at the sapheno-femoral junction or at the sapheno-popliteal junction.

→ ABPI is used to assess if there is any arterial insufficiency playing a role so that we know if we can perform compression therapy. An ABPI >0.6 is needed.

→ Swab may be used to assess if there is any infection and if antibiotics are needed.

🧰 Management

Once again we can have 3 types of treatment:

  1. Conservative
    1. Lifestyle changes such as smoking cessation, weight loss, and exercise.
    2. Leg elevation
  2. Medical
    1. 🏆 Compression bandaging changed weekly/biweekly. ABPI >0.6 is required.
    2. Antibiotics to be prescribed only in cases of wound infection.
  3. Surgical - if there are concurrent varicose veins, they need to be treated through open/endovenous surgery.
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