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Venous Stasis UlcerAka: Venous Ulcer

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  1. Cause
    1. See Venous Insufficiency
    2. See Venous Stasis
  2. Epidemiology
    1. More common in women
  3. Risk factors
    1. Prior leg injury
    2. Obesity
    3. Phlebitis
    4. Varicose veins or related surgery
    5. Prolonged standing or sitting
    6. Deep Vein Thrombosis
  4. Symptoms
    1. Aching pain at ulcer site
    2. Sensation of limb heaviness
    3. Leg Pain increases late in the day
    4. Pain relieved with elevating legs
  5. Signs
    1. Medial malleolus most often affected
    2. Irregular, flat border
    3. Associated findings
      1. Dependent edema
      2. Varicose veins
      3. Purpura
      4. Red-brown Skin Discoloration
      5. Venous dermatitis (eczematous changes)
  6. Differential Diagnosis
    1. Arterial Insufficiency related ulcer
    2. Vasculitic Disease related ulcer
    3. Skin malignancy
  7. Labs: Biopsy non-healing ulcer
    1. Evaluate for Vasculitis or malignancy
    2. Other tests to confirm Venous Stasis as cause
      1. Duplex ultrasound
  8. Management: First-line options (most effective measures)
    1. Pearls
      1. Maintain moist wound environment (e.g. Aquaphor)
      2. Debride slough and necrotic tissues
        1. See Wound Cleansing
        2. See Wound Debridement
    2. Keep leg up above heart level 30 minutes 3-4 times/day
    3. Compression of edematous limb (e.g. stockings)
      1. See Compression stockings
      2. See Venous Insufficiency
      3. Most effective strategy
    4. Antibiotics
      1. Decide if antibiotics are appropriate
        1. Most lesions are chronically colonized
        2. Antibiotics do not sterilize lesions
        3. Treat acute infections
      2. Base antibiotic use on tissue culture
    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. 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
    6. Adjuncts
      1. Pentoxifylline (Trental)
        1. Cost effective adjunct speeds venous ulcer healing
        2. Jull (2002) Lancet 359:1550
      2. Aspirin
        1. Consider as alternative
  9. Management: Second-line options (studies suggest benefit)
    1. Cultured allogenic bilayer skin replacement
    2. Oral flavinoids
    3. Oral Sulodexide
    4. Peri-ulcer injection
      1. Granulocyte-Macrophage Colony Stimulating Factor
    5. Systemic Mesoglycan
    6. Hyperbaric oxygen
    7. Vacuum assisted wound closure (VAC)
    8. Skin grafting (e.g. Oasis, APLIGRAF)
  10. Management: Strategies with unknown efficacy
    1. Unna Boot
      1. Contraindicated if significant wound drainage
      2. Graduated compression
        1. Maximal compression at ankle
        2. No compression at top of boot
    2. Enzymatic Debriding agents
      1. Unproven
    3. Silver sulfadiazine
      1. Unclear whether improves wound healing
    4. Topical Autologous Platelet Lysate
      1. Approved for diabetic wounds only
    5. Hydrocolloid Dressings
  11. 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
  12. Course
    1. Heals with treatment at 40 to 120 days in most cases
    2. Persistent ulcer at one year in 25% of cases
  13. Prevention
    1. Compression stockings prevent ulcer recurrence
    2. Consider venous recanalization for venous obstruction
    3. Consider venous ablation for venous incompetency
  14. References
    1. De Araujo (2003) Ann Intern Med 138:326
    2. Nelson (2005) Am Fam Physician 71(7):1365
    3. Weingarten (2001) Clin Infect Dis 32:949

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