II. Epidemiology

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

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 and fluid 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. Distribution
    1. Supramalleolar lesions (gaiter region)
    2. Typically over bony prominence (esp. medial malleolus)
  2. Lesion characteristics
    1. Irregular, flat, well-defined border
    2. Shallow wound site
    3. No eschar, but typically with overlying Fibrin and granulation tissue
  3. Associated findings of venous Hypertension (see Venous Insufficiency)
    1. Dependent Edema (typically pitting)
    2. Varicose Veins
    3. Purpura
    4. Red-brown Skin Discoloration (hemosiderin staining)
    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
    1. Typically deep, round, punched-out lesions with sharply demarcated edges and a yellow, necrotic base
    2. Often localized to the lateral malleolus, pretibial region or dorsal foot and toes
    3. Associated findings of Arterial Insufficiency (decreased peripheral pulses, cool distal limbs with loss of distal limb hair)
  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. Peripheral Pulses AND
      2. Ankle-Brachial Index (ABI) or Arterial Doppler
    2. Venous Insufficiency confirmation (and exclude obstruction)
      1. Duplex Ultrasound

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

  1. General measures
    1. See TIME Principle of Chronic Wound Care
    2. Elevate leg up above heart level 30 minutes 3-4 times/day, for 6 days per week
    3. Progressive resistance Exercises (e.g. ankle Exercises) and prescribed Physical Activity (e.g. walking)
    4. Maintain topical Emollient for moist Wound Healing (e.g. Aquaphor)
  2. 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]
  3. 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
      1. Evaluate for comorbid Peripheral Arterial Disease and avoid if Ankle-Brachial Index <0.6
    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)
      1. Associated with decreased pain, and faster and more complete Venous Ulcer healing
      2. Shi (2021) Cochrane Database Syst Rev (7): CD013397 [PubMed]
    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
  4. 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 (e.g. Simvastatin, Atorvastatin)
      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 (Zinc Oxide compression bandage)
    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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