venous stasis ulcer

Introduction

Ulceration associated with ambulatory venous hypertension.

Etiology

• chronic venous insufficiency
• incompetence of deep vein valves
• deep vein thrombosis

Clinical manifestations

• ulcer is generally not painful unless secondarily infected
  • symptoms range from not painful to significant pain
• generally between knee & ankle, medial along the course of the long saphenous vein, especially the region of the medial malleolus
• often associated aching & swelling of lower leg aggravated by standing
• untreated ulcers generally have exudate
  • exudate is generally serosanguineous or purulent
  • signs of secondary infection
    • fecal odor
    • surrounding erythema
    • fever
• surrounding skin often has edema & brown discoloration (hemosiderin)
• varicosities are generally present
• occasional induration & inflammation of the dermis & subcutaneous fat

For staging of ulcers see pressure (decubitus ulcer)

* images

Laboratory

• wound cultures generally reveal polymicrobial flora
  • generally not helpful
  • culture from base of wound after cleansing if compelled to do so
• blood cultures if systemic infection suspected
• ultrasound-doppler if suspecting deep vein thrombosis

Diagnostic procedures

• assess arterial status prior to application of compression
  • ankle-brachial index
    • not necessary if pulses normal & arterial ulcer not suspected

Complications

• osteomyelitis

Differential diagnosis

• arterial ulcer (for comparison see)
• neuropathic ulcers occur primarily on plantar aspect of foot
• pyoderma gangrenosum is painful

Management

• address underlying chronic venous insufficiency
• diuresis to treat congestive heart failure
• necrotic tissue must be removed to promote healing
• venous compression to reduce venous stasis & edema
  • elastic stockings
  • zinc oxide bandages (Unna boot) for venous leg ulcers on the medial malleolus
  • elastic wraps (ACE bandage)
  • colloid wrap (Duoderm)
  • treatment of choice
• dressing
  • hydrocolloid dressings perform no better than simple non-adherant dressings
  • moist wound surface may promote wound healing
  • wet to dry dressing to remove necrotic tissue followed by moist saline dressings
    • dry dressing disrupts formation of granulation tissue when removed
  • betadine, hydrogen peroxide, Dakin's solution (KOCl) & acetic acid inhibit wound healing by cytotoxicity
  • silver sulfadiazine
• treat systemic infection & cellulitis
  • systemic antibiotics (see cellulitis)
  • reserve systemic anibiotics for clinically infected ulcers
• calcipotriene (Dovonex)
• pentoxifylline in addition to venous compression
  • 400-800 mg PO TID
  • cilostazol (Pletal) may be alternative
• addition of exercise to compression of benefit
• aspirin 300 mg/day of benefit
  • aspirin 150 mg/day of no benefit
• good nutritional support
• maintain adequate circulation
• surgery
  • selected patients who fail medical management
  • early endovenous ablation of superficial venous reflux (within 2 weeks) reduces time to ulcer healing (56 vs 82 days for venous compression)
  • early endovenous ablation lowers incidence of recurrent ulcers
• investigational therapy
  • autologous platelet-rich plasma therapy
  • spray-on allogeneic skin cells may be of benefit
  • simvastatin 40 mg/day reportedly heals 100% of stasis ulcers <= 5 cm in size in 10 weeks (vs 46% of controls)
  • topical beta-blocker may be of benefit
  • electromagnetic therapy of no benefit
• patient education
  • avoid heating pads & ice packs to prevent thermal injury
  • avoid prolonged standing
  • avoid sitting with legs crossed
  • ambulate intermittently
  • use moisturizer: Eucerin or alpha Keri on surrounding skin

More general terms

• cutaneous ulcer
• chronic skin disease

Additional terms

• arterial ulcer
• neuropathic ulcer
• pressure ulcer (decubitus ulcer, bedsore)
• venous stasis; venous hypertension