II. Epidemiology

  1. More common in women
  2. Prevalence: 1-3% in U.S. (4% of those over age 65 years)

III. Pathophysiology

  1. See Venous Insufficiency
  2. Venous Stasis Ulcers form in areas of venous Hypertension
    1. Higher venous pressures are due to venous reflux or venous obstruction
  3. Venous circulation inflammation (vein wall, or venous valve leaflets)
    1. Inflammatory factors extravasate into the interstitial space

IV. Risk Factors

  1. Over age 55 years
  2. Prior leg injury
  3. Obesity
  4. Phlebitis
  5. Varicose Veins or related surgery
  6. Prolonged standing or sitting
  7. Deep Vein Thrombosis history
  8. Family History of Chronic Venous Insufficiency or parental history of Venous Ulcers
  9. Multiple pregnancies
  10. Severe Lipodermatosclerosis (Panniculitis with secondary skin hardening and swelling)

V. Symptoms

  1. Aching pain or Pruritus at ulcer site
  2. Sensation of limb heaviness
  3. Leg Pain and swelling increases late in the day
  4. Pain and swelling relieved with elevating legs

VI. Signs

  1. Medial malleolus most often affected
  2. Irregular, flat, well-defined border
  3. Associated findings (see Venous Insufficiency)
    1. Dependent Edema
    2. Varicose Veins
    3. Purpura
    4. Red-brown Skin Discoloration
    5. Venous Dermatitis (Eczematous changes)

VII. Differential Diagnosis

  1. See Leg Ulcer Causes
  2. See Foot Ulcer
  3. See Skin Ulcer
  4. Arterial Insufficiency related ulcer
  5. Vasculitic Disease related ulcer
  6. Peripheral Neuropathy related ulcer
    1. Neuropathic Foot Ulcer (Diabetic Foot Ulcer)
  7. Pressure Ulcer
  8. Skin malignancy
  9. Pyoderma Gangrenosum
  10. Skin Ulcers related to other conditions
    1. Calciphylaxis
    2. Vasculitis
    3. Autoimmune Conditions
    4. Sickle Cell Anemia

VIII. Evaluation: Non-healing ulcer

  1. Biopsy
    1. Evaluate for Vasculitis or malignancy
  2. Vascular evaluation
    1. Peripheral Arterial Disease
      1. Ankle-Brachial Index (ABI) or
      2. Arterial Doppler
    2. Venous Insufficiency confirmation (and exclude obstruction)
      1. Duplex Ultrasound

IX. Management: First-line options (most effective measures)

  1. General measures
    1. Keep leg up above heart level 30 minutes 3-4 times/day, for 6 days per week
    2. Progressive resistance Exercises (e.g. ankle Exercises) and prescribed Physical Activity (e.g. walking)
  2. Maintain moist wound environment (e.g. Aquaphor)
  3. Debride slough and necrotic tissues
    1. See Wound Cleansing
    2. See Wound Debridement
    3. Sharp Debridement, Enzymatic Debridement and Autolytic Debridement are preferred over Mechanical Debridement
      1. Mechanical Debridement (Wet-to-Dry Dressings, pulsed lavage, whirlpool) is used less than other methods
      2. However, Wet-to-Dry Dressings are among the most cost effective measures (see below)
    4. Purely Venous Stasis Ulcers need minimal debridement
      1. If significant debridement required than consider alternative diagnoses
    5. Wound Debridement at each provider visit results in reduced wound size
      1. Cardinal (2009) Wound Repair Regen 17(3): 306-11 [PubMed]
  4. Compression of edematous limb (e.g. elastic graded-Compression stockings)
    1. See Compression stockings
    2. See Venous Insufficiency
    3. Contraindicated in Peripheral Arterial Disease and uncompensated Congestive Heart Failure
    4. Limited use if wound drainage, significant pain, leg deformity and difficulty self-applying compression
      1. Donning butler or stockings with easier closure (e.g. velcro or zipper) may be considered
    5. Most effective strategy, but adequate pressures must be reached (30-44 mmHg are preferred at knee and hip)
    6. Compression stockings are removed each night
      1. Replace with new Compression stockings every 6 months (compression lost as they are repeatedly washed)
    7. Multi-layer compression systems (with an elastic component) are most effective
  5. Dressings
    1. No advantage of one type dressing versus another
    2. Options
      1. Wet-to-Moist Dressings are most cost-effective
        1. Similar efficacy to more expensive options
        2. However,
      2. Vaseline-gauze (Adaptic)
      3. Occlusive hydrocolloid (e.g. Duoderm)
        1. May be more convenient and better pain reduction
      4. Agents lower colonized Bacterial load
        1. Silver products (e.g. Acticoat)
        2. Xeroform
    3. Example Dressing
      1. Layer 1: Hydrogel Dressing (e.g. Duoderm Gel)
      2. Layer 2: Foam Dressing
      3. Layer 3: Compression Wrap

X. Management: Systemic Medications

  1. Antibiotics
    1. Decide if antibiotics are appropriate
      1. Most lesions are chronically colonized
      2. Antibiotics do not sterilize lesions
      3. Treat acute infections (Cellulitis)
    2. Base antibiotic use on tissue culture
  2. Adjuncts
    1. Pentoxifylline (Trental)
      1. Cost effective adjunct speeds Venous Ulcer healing
      2. Jull (2002) Lancet 359:1550-4 [PubMed]
    2. Aspirin 325 mg daily
      1. Consider as alternative agent to Trental (variable evidence)
    3. Statins
      1. Limited evidence of improved ulcer healing
      2. Evangelista (2014) Br J Dermatol 170(5): 1151-7 [PubMed]

XI. Management: Second-line options

  1. Cellular and tissue based products (the following are examples, not a complete list)
    1. Cultured allogenic bilayer skin replacement
    2. Peri-ulcer injection
      1. Granulocyte-Macrophage Colony Stimulating Factor
    3. Systemic Mesoglycan
  2. Skin grafting
    1. Indicated in large Venous Ulcers >25 cm^2
    2. Not effective if edema persists or underlying Venous Insufficiency goes untreated
  3. Endovenous intervention
    1. Endovenous ablation, ligation or sclerotherapy

XII. Management: Strategies with unknown efficacy or mixed results

  1. Unna Boot
    1. Contraindicated if significant wound drainage
    2. Graduated compression
      1. Maximal compression at ankle
      2. No compression at top of boot (contrast with elastic compression stocking)
  2. Silver sulfadiazine
    1. Unclear whether improves Wound Healing
  3. Topical Autologous Platelet Lysate
    1. Approved for diabetic wounds only
  4. Hydrocolloid Dressings
  5. Hyperbaric oxygen
    1. No proven benefit
  6. Vacuum assisted wound closure (VAC)
    1. Insufficient evidence to support use in terms of clinically useful outcomes
  7. Oral Sulodexide
  8. Phlebotonics
    1. Do not appear to improve Venous Ulcer healing (but may improve edema and symptoms)
    2. Oral flavinoids (rutosides, diosmin, hesperidin)
    3. Saponins (Horse chestnut seed extract)

XIII. Management: Stratagies to avoid

  1. Avoid Topical Antibiotics
    1. Antibiotics do not improve ulcer healing
  2. Avoid Topical antiseptics (e.g. povidone-Iodine)
    1. Causes wound injury and delays healing

XIV. Course

  1. Heals with treatment at 40 to 120 days in most cases
  2. Persistent ulcer at one year in 25% of cases
  3. Recurrence of Venous Ulcers in up to 70% of cases

XV. Prognosis: Predictors of worse prognosis

  1. Venous Ulcer present >3 months
  2. Venous Ulcer longer than 10 cm
  3. Lower extremity Peripheral Arterial Disease
  4. Obesity
  5. Advanced age

XVI. Complications

  1. Infection
  2. Squamous cell cancer
  3. Venous Ulcer related Chronic Pain

XVII. Prevention

  1. Compression stockings prevent ulcer recurrence (contraindicated if ABI <0.8)
  2. Consider venous recanalization for venous obstruction
  3. Consider venous ablation for venous incompetency

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Ontology: Varicose Ulcer (C0042344)

Definition (MSH) Skin breakdown or ulceration caused by varicose veins in which there is too much hydrostatic pressure in the superficial venous system of the leg. Venous hypertension leads to increased pressure in the capillary bed, transudation of fluid and proteins into the interstitial space, altering blood flow and supply of nutrients to the skin and subcutaneous tissues, and eventual ulceration.
Concepts Disease or Syndrome (T047) , Acquired Abnormality (T020)
MSH D014647
SnomedCT 201255001, 238791004, 155463002, 41915009, 371032004, 402863005
LNC MTHU021405
English Venous Ulcer, Stasis Ulcer, Stasis Ulcers, Ulcers, Stasis, Ulcers, Varicose, Varicose Ulcers, Ulcer, Venous, Ulcers, Venous, Venous Ulcers, Ulcer, Stasis, Ulcer, Varicose, VARICOSE ULCERATION, Ulcers, Venous Stasis, Venous Hypertension Ulcer, Hypertension Ulcer, Venous, Ulcer, Venous Hypertension, Stasis Ulcer, Venous, Stasis Ulcers, Venous, Venous Stasis Ulcer, Venous Hypertension Ulcers, Hypertension Ulcers, Venous, Ulcers, Venous Hypertension, Venous Stasis Ulcers, Ulcer, Venous Stasis, venous stasis ulcer (diagnosis), venous stasis ulcer, venous stasis, Venous stasis ulcer, Venous ulcer NOS, Ulcerated varicose veins, Varicose ulceration, Varicose veins (with ulceration), Venous ulceration, Varicose Ulcer [Disease/Finding], varicose ulcers, venous ulcer, venous ulcers, stasis ulcers, ulcerated varicose veins, ulceration venous, stasis venous ulcers, venous leg ulcer, leg ulcers venous, Ulcer;varicose, stasis ulcer, ulcer varicose, ulcers stasis, ulcers venous, ulcer venous, venous ulceration, stasis leg ulcer, stasis ulcers venous, ulcerations venous, venous stasis ulcers, Varicose Ulcer, Venous ulcer, Gravitational ulcer, Stasis leg ulcer, Stasis ulcer, Varicose ulcer, Venous ulcer of leg, Stasis ulcer (disorder), Stasis ulcer (morphologic abnormality), Venous ulcer of leg (disorder), stasis; ulcer, ulcer; stasis, ulcer; varicose, varicose; ulcer, Stasis ulcer of leg, varicose ulcer
French ULCERE VARIQUEUX, Ulcère veineux de stase, Ulcère veineux SAI, Ulcération veineuse, Veines variqueuses (avec ulcération), Veines variqueuses ulcérées, Ulcère de stase, Ulcération d'une varice, Ulcère variqueux
Italian Ulcerazione varicosa, Ulcerazione venosa, Ulcera da stasi, Ulcera da stasi venosa, Vene varicose ulcerate, Vene varicose (con ulcerazione), Ulcera venosa NAS, Ulcera venosa, Ulcere da ipertensione venosa, Ulcere da stasi, Ulcere venose da stasi, Ulcera varicosa
Dutch veneuze zweer NAO, veneuze ulceratie, ulcererende spataderen, ulcus door stase, spataderen (met ulceratie), ulcus door veneuze stase, stase; ulcus, ulcus; stase, ulcus; variceus, variceus; ulcus, variceus ulcus, Stase-ulcus, Ulcus varicosum, Veneus ulcus
German Varizen mit Ulzeration, venoeses Stauungsulkus, venoeses Ulkus, venoeses Ulkus NNB, Varizen (mit Ulzeration), Stauungsulkus, varikoese Ulzeration, Ulcus varicosum, Ulcus venosum, Geschwür, variköses
Portuguese Úlcera venosa NE, Veias varicosas (com ulceração), Úlcera de estase venosa, Úlcera de estase, Ulceração venosa, Veias varicosas ulceradas, ULCERACAO VARICOSA, Ulceração varicosa, Úlcera Varicosa, Úlcera Venosa, Úlcera por Estase
Spanish Venas varicosas (con ulceración), Úlcera venosa NEOM, Úlcera por estasis venosa, Venas varicosas ulceradas, Ulceración venosa, úlcera por estasia, úlcera varicosa, Úlcera por estasis, úlcera de la pierna por estasis, úlcera gravitacional, úlcera por estasis (anomalía morfológica), úlcera por estasis (trastorno), úlcera por estasis, úlcera venosa de pierna (trastorno), úlcera venosa de pierna, úlcera venosa, Ulceración varicosa, Úlcera por Estasis, Úlcera Varicosa, Úlcera Venosa
Japanese 静脈性潰瘍NOS, 静脈性潰瘍, 静脈瘤(潰瘍性), 静脈うっ滞性潰瘍, うっ滞性潰瘍, ジョウミャクリュウセイカイヨウ, ウッタイセイカイヨウ, ジョウミャクリュウカイヨウセイ, ジョウミャクセイカイヨウ, ジョウミャクウッタイセイカイヨウ, ジョウミャクセイカイヨウNOS, 鬱血性潰瘍, 欝血性潰瘍, 静脈潰瘍, うっ血性潰瘍, 静脈瘤性潰瘍
Swedish Venöst bensår
Czech ulcus cruris, varikózní vředy, bércové vředy, Vřed z městnání, Varikózní ulcerace, Ulcerované křečové žíly, Vřed při venostáze, Venózní ulcerace, Venózní vřed NOS, otevřená noha
Finnish Laskimoperäinen säärihaava
Russian VARIKOZNAIA IAZVA, TSIRKULIATORNAIA VARIKOZNAIA IAZVA, ВАРИКОЗНАЯ ЯЗВА, ЦИРКУЛЯТОРНАЯ ВАРИКОЗНАЯ ЯЗВА
Croatian VARIKOZNI ULKUS
Polish Owrzodzenie żylne, Owrzodzenie żylakowate
Hungarian Vénás stasis fekély, Vénás ulceratio, Stasis fekély, Exulcerált varicosus venák, Varicosus ulceratio, Varicosus venák (ulceratióval), Venás fekély k.m.n.
Norwegian Venøst bensår, Varikøst beinsår, Venøst beinsår, Venestuvningsår, Stuvningsår, Varikøst bensår