Venous Ulcers

Venous ulcers, also known as venous insufficiency ulceration, stasis ulcers, and varicose ulcers, are chronic wounds predominantly found in the ankle region. Defined by the American Venous Forum as full-thickness skin defects that fail to heal spontaneously, these ulcers are sustained by chronic venous disease, typically diagnosed via venous duplex ultrasound.

Affecting about 1% of the population, venous ulcers are a significant cause of chronic wounds, often resulting from improper functioning of venous valves in the legs.

Venous ulcer on the back of the right leg

Signs and Symptoms

Venous ulcers commonly present with moderate pain that improves upon elevation. The ulcers have irregular, sloping edges and are often accompanied by oedema due to increased hydrostatic pressure. Other symptoms include localised loss of skin pigmentation known as 'atrophie blanche', hardening of the skin termed lipodermatosclerosis, and associated superficial varicose veins or "ankle flare". The ulcers usually develop along the medial distal leg and negatively impact the quality of life.

Venous ulcer before surgery

Healing process of a chronic venous stasis ulcer of the lower leg

Healing venous ulcer after one month

Pathophysiology

Venous ulcers arise mainly due to venous stasis, often caused by chronic venous insufficiency or congestive heart failure, leading to increased venous pressure. This results in ineffective blood flow, causing the leakage of blood proteins into the extravascular space, which hinders wound healing. Accumulation of white blood cells and inflammatory factors further contributes to the formation of chronic wounds. Venous stasis ulcers typically appear in the lower extremities due to damage to the venous valvular system.

Diagnosis

Diagnosis involves clinical assessment and may include venous duplex ultrasound to confirm chronic venous disease. The CEAP classification system (clinical, aetiology, anatomy, and pathophysiology) helps assess the severity of the ulcers. Distinguishing venous ulcers from arterial ulcers is very important; venous ulcers are usually found on the medial leg with irregular edges, while arterial ulcers appear on the lateral leg and bony prominences with a punched-out appearance.

Venous ulcer (45 x 30 mm)

Treatment

Treatment aims to create an environment conducive to skin growth. This often involves addressing underlying venous reflux and using compression therapy, which enhances healing by reducing venous pressure. Compression stockings, exercise, and patient education are very important components. The NICE guidelines recommend referral to a vascular specialist for all venous leg ulcers.

Antibiotics are typically reserved for cases of infection, while topical agents like cadexomer iodine have shown benefits. The use of medical-grade honey is supported by some evidence, though not conclusively. There is uncertainty regarding the effectiveness of various dressings and the role of therapeutic ultrasound.

Compression Therapy

Compression therapy is essential for managing venous ulcers, as it decreases vein diameter and pressure, facilitating blood flow and reducing inflammation. Elastic bandages, compression stockings, and intermittent pneumatic compression devices are commonly used. Research indicates that compression dressings can reduce pain and expedite healing.

Medications

Medications like pentoxifylline and sulodexide may aid in healing by reducing platelet aggregation and inflammation. Aspirin and oral zinc supplements are under investigation, though their efficacy is not yet confirmed.

Skin Grafts and Artificial Skin

Skin grafts from animal sources and artificial skin made of collagen and cultured cells can promote healing by providing a scaffold for new tissue growth.

Surgery

Surgical interventions, including endovenous ablation and foam sclerotherapy, have shown success in reducing ulcer recurrence and promoting healing. These techniques, particularly when combined with compression therapy, offer promising outcomes.

Dressings

The efficacy of various dressings remains uncertain, though silver-containing dressings and ibuprofen dressings for pain relief have shown some promise.

Chronic venous insufficiency & Venous ulcer

Self-assessment MCQs (single best answer)

What is the primary cause of venous ulcers?

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Which diagnostic tool is commonly used to confirm chronic venous disease in the context of venous ulcers?

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Venous ulcers are most commonly found in which location on the body?

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What is the role of compression therapy in the treatment of venous ulcers?

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Which symptom is NOT typically associated with venous ulcers?

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Which classification system is used to assess the severity of venous ulcers?

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Which of the following is a commonly used topical agent in the treatment of venous ulcers?

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Which medication has shown potential benefits in healing venous ulcers by reducing platelet aggregation and inflammation?

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What type of surgical interventions are used to treat venous ulcers?

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Which of the following is NOT a recommended component of venous ulcer management?

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