II. Cause

III. Epidemiology

  1. More common in women

IV. 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

V. 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

VI. 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)

VII. Differential Diagnosis

  1. See Leg Ulcer Causes
  2. See Foot Ulcer
  3. Arterial Insufficiency related ulcer
  4. Vasculitic Disease related ulcer
  5. Peripheral Neuropathy related ulcer
    1. Neuropathic Foot Ulcer
  6. Pressure Ulcer
  7. Skin malignancy

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
      1. Duplex Ultrasound

IX. 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
      3. Purely Venous Stasis Ulcers need minimal debridement
      4. If significant debridement required than consider alternative diagnoses
  2. Keep leg up above heart level 30 minutes 3-4 times/day
  3. Compression of edematous limb (e.g. elastic graded-Compression stockings)
    1. See Compression stockings
    2. See Venous Insufficiency
    3. Most effective strategy, but adequate pressures must be reached (30-44 mmHg are preferred at knee and hip)
    4. Compression stockings must be changed every 6 months
  4. 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
  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 359:1550-4 [PubMed]
    2. Aspirin 325 mg daily
      1. Consider as alternative

X. Management: Second-line options

  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
    1. No proven benefit
  7. Vacuum assisted wound closure (VAC)
    1. Insufficient evidence to support use in terms of clinically useful outcomes
  8. Skin grafting (e.g. Oasis, APLIGRAF)
    1. Not effective if edema persists or underlying Venous Insufficiency goes untreated

XI. 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 (contrast with elastic compression stocking)
  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

XII. 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

XIII. Course

  1. Heals with treatment at 40 to 120 days in most cases
  2. Persistent ulcer at one year in 25% of cases

XIV. Prevention

  1. Compression stockings prevent ulcer recurrence
  2. Consider venous recanalization for venous obstruction
  3. Consider venous ablation for venous incompetency

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