Venous Ulcers; causes treatment and management

Venous ulcers

Venous ulcers are chronic skin and subcutaneous lesions usually found on the lower extremity at the pretibial and the medial supra-malleolar areas of the ankle, where the perforator veins are located. Venous ulcers were formerly known as “venous stasis” ulcers because their development was thought to be caused by blood pooled in the veins. More recent literature indicates that venous hypertension rather than venous stasis is both the cause of these ulcers and the reason they don’t heal. It’s difficult to restore skin integrity in the presence of chronic venous hypertension because the underlying edema must be controlled in addition to healing the ulcer.

Venous Ulcers

 

CHARACTERISTICS OF VENOUS ULCERS

Venous hypertension distends the superficial veins, resulting in vein wall damage and exudation of fluid into the interstitial space, thereby causing edema of venous insufficiency. Over time, an actual leakage of red blood cells occurs through these compromised veins. As they break down, the red blood cells deposit hemosiderin into the tissues, causing a form of “internal tattooing” of the skin; the coloration is that of a brownish hue noticeable even in black skin. (See Hemosiderin deposit.) The skin loses its normal texture and becomes somewhat shiny and subsequently sclerotic, giving a taut skin appearance in these areas.

Edema and loss of red cells into the subcutaneous tissue occur at the point of greatest gravitational pressure, the ankle. This gives rise to the pathopneumonic features of chronic venous stasis, hyperpigmentation, and stocking distribution induration of the subcutaneous tissues, the characteristics of long-standing venous insufficiency called lipodermatosclerosis. Another sequelae of venous hypertension is irritability of the musculature. Many patients with venous insufficiency—even those in whom the condition is mild—report nocturnal leg cramps. Depolarization may occur due to fluid distention of the muscular cells, causing tetanic-like contractions of various muscle groups. Distention of veins in the subdermal plexus results in the varicosities typically seen with venous insufficiency.

Venous leg ulcers are also correlated with increased ambulatory venous pressures. Nicolaides21 obtained ambulatory venous pressure (AVP) from 220 patients admitted with venous problems. He found that no patients with an AVP less than 30 mm Hg had leg ulcers, while 100% of those with AVP greater than 90 mm.

 Venous testing

It’s possible to perform a crude venous assessment by physical exam using a Doppler ultrasound. By compressing the limb manually, the fl ow in the veins can be augmented and noted by the audible Doppler signal heard distal to the site of compression. This is a subjective test, and reliability is clinician dependent. The introduction of noninvasive vascular testing has provided much anatomical and physiological information to increase the accuracy of diagnosing venous diseases. Two tests are most commonly used to assess the severity of venous insufficiency. One is venous photoplethysmography (PPG), and the other is venous duplex imaging. Hg had ulcers. The incidence of ulceration wasn’t preferentially associated with either superficial or deep venous disease.

 

TREATING VENOUS ULCERS

Treatment goals for all ulcers are to:

• provide an environment conducive to new tissue growth

• protect the wound

• prevent further tissue destruction.

Topical and systemic treatments are addressed simultaneously. It’s imperative to consider the cause when deciding treatment because ulcers aren’t all alike and treatment for one type may be inappropriate or harmful for another type. A vascular specialist consultation is appropriate for ulcers of mixed etiology.

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