Dressings are beneficial for venous ulcer healing, but no dressing has been shown to be superior. Pentoxifylline Trental is effective when used with compression therapy for venous ulcers, and may be useful as monotherapy. Aspirin mg per day is effective when used with compression therapy for venous ulcers. The pathophysiology of venous ulcers is not entirely clear.
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Venous incompetence and associated venous hypertension are thought to be the primary mechanisms for ulcer formation. Factors that may lead to venous incompetence include immobility; ineffective pumping of the calf muscle; and venous valve dysfunction from trauma, congenital absence, venous thrombosis, or phlebitis.
Leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema contribute to venous ulcer development and impaired wound healing. Determining etiology is a critical step in the management of venous ulcers. Characteristic differences in clinical presentation and physical examination findings can help differentiate venous ulcers from other lower extremity ulcers Table 1. Shallow, painful ulcer located over bony prominences, particularly the gaiter area over medial malleolus ; granulation tissue and fibrin present.
Leg elevation, compression therapy, aspirin, pentoxifylline Trental , surgical management. Associated findings include edema, venous dermatitis, varicosities, and lipodermatosclerosis. Associated with cardiac or cerebrovascular disease; patients may present with claudication, impotence, pain in distal foot; concomitant with venous disease in up to 25 percent of cases.
Differential diagnosis of chronic leg ulcers - Servier - PhlebolymphologyServier – Phlebolymphology
Ulcers are commonly deep, located over bony prominences, round or punched out with sharply demarcated borders; yellow base or necrosis; exposure of tendons Associated findings include abnormal pedal pulses, cool limbs, femoral bruit and prolonged venous filling time. Usually occurs on plantar aspect of feet in patients with diabetes, neurologic disorders, or Hansen disease. Located over bony prominences; risk factors include excessive moisture and altered mental status. Off-loading of pressure; reduction of excessive moisture, sheer, and friction; adequate nutrition.
Managing the patient with venous ulcers. Ann Intern Med. Venous stasis commonly presents as a dull ache or pain in the lower extremities, swelling that subsides with elevation, eczematous changes of the surrounding skin, and varicose veins. The recurrence of an ulcer in the same area is highly suggestive of venous ulcer. On physical examination, venous ulcers are generally irregular and shallow Figure 1. Granulation tissue and fibrin are often present in the ulcer base. Other findings include lower extremity varicosities; edema; venous dermatitis associated with hyperpigmentation and hemosiderosis or hemoglobin deposition in the skin; and lipodermatosclerosis associated with thickening and fibrosis of normal adipose tissue under skin.
A clinical severity score based on the CEAP clinical, etiology, anatomy, and pathophysiology classification system can guide the assessment of chronic venous disorders. The highest CEAP severity score is applied to patients with ulcers that are active, chronic greater than three months' duration, and especially greater than 12 months' duration , and large larger than 6 cm in diameter. Treatment options for venous ulcers include conservative management, mechanical treatment, medications, and surgical options Table 2.
Although numerous treatment methods are available, they have variable effectiveness and limited data to support their use. Standard of care; proven benefit benefit of intermittent pneumatic therapy is less clear ; associated with decreased rate of ulcer recurrence. Standard of care when used with compression therapy; minimizes edema; recommended for 30 minutes, three or four times a day. Intravenous administration not available in the United States may be beneficial, but data are insufficient to recommend its use; high cost limits use.
Oral antibiotic treatment is warranted in cases of suspected cellulitis; routine use of systemic antibiotics provides no healing benefit; benefit of adding the topical antiseptic cadexomer iodine not available in the United States is unclear. May be beneficial when used with compression therapy; concern about infection transmission. May be beneficial for severe or refractory cases; associated with decreased rate of ulcer recurrence.
Information from references 1 , 2 , 7 , 10 , 19 , and 22 through Compression therapy is the standard of care for venous ulcers and chronic venous insufficiency. Compression therapy reduces edema, improves venous reflux, enhances healing of ulcers, and reduces pain.
Inelastic compression therapy provides high working pressure during ambulation and muscle contraction, but no resting pressure. The most common method of inelastic compression therapy is the Unna boot, a zinc oxide—impregnated, moist bandage that hardens after application. The Unna boot improves healing rates compared with placebo or hydroactive dressings.
In addition, the Unna boot may lead to a foul smell from the accumulation of exudate from the ulcer, requiring frequent reapplications. Unlike the Unna boot, elastic compression therapy methods conform to changes in leg size and sustain compression during both rest and activity. Stockings or bandages can be used; however, elastic wraps e. Compression stockings are removed at night, and should be replaced every six months because they lose pressure with regular washing. Elastic bandages e. A recent meta-analysis showed that elastic compression therapy is more effective than inelastic therapy.
Intermittent Pneumatic Compression. Intermittent pneumatic compression therapy comprises a pump that delivers air to inflatable and deflatable sleeves that embrace extremities, providing intermittent compression.
Venous leg ulcers: Pathophysiology and Classification
It also is expensive and requires immobilization of the patient; therefore, intermittent pneumatic compression is generally reserved for bedridden patients who cannot tolerate continuous compression therapy. Leg elevation when used in combination with compression therapy is also considered standard of care. Leg elevation requires raising lower extremities above the level of the heart, with the aim of reducing edema, improving microcirculation and oxygen delivery, and hastening ulcer healing.
In one small study, leg elevation increased the laser Doppler flux i. Dressings are often used under compression bandages to promote faster healing and prevent adherence of the bandage to the ulcer. A wide range of dressings are available, including hydrocolloids e. Without clear evidence to support the use of one dressing over another, the choice of dressings for venous ulcers can be guided by cost, ease of application, and patient and physician preference.
Topical negative pressure, also called vacuum-assisted closure, has been shown to help reduce wound depth and volume compared with a hydrocolloid gel and gauze regimen for wounds of any etiology. There is currently insufficient high-quality data to support the use of topical negative pressure for venous ulcers.
Pentoxifylline Trental is an inhibitor of platelet aggregation, which reduces blood viscosity and, in turn, improves microcirculation. Pentoxifylline mg three times per day has been shown to be an effective adjunctive treatment for venous ulcers when added to compression therapy. Despite a number of studies to support its effectiveness as adjunctive therapy, and possibly as monotherapy, the cost-effectiveness of pentoxifylline has not been established.
Like pentoxifylline therapy, aspirin mg per day combined with compression therapy has been shown to increase ulcer healing time and reduce ulcer size, compared with compression therapy alone. The synthetic prostacyclin iloprost is a vasodilator that inhibits platelet aggregation. In one study, intravenous iloprost not available in the United States used with elastic compression therapy significantly reduced healing time of venous ulcers compared with placebo.
Zinc is a trace metal with potential anti-inflammatory effects. Oral zinc therapy has been shown to decrease healing time in patients with pilonidal sinus. However, in a recent meta-analysis of six small studies, oral zinc had no beneficial effect in the treatment of venous ulcers.
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Bacterial colonization and superimposed bacterial infections are common in venous ulcers and contribute to poor wound healing. However, a recent Cochrane review of 22 RCTs of systemic and topical antibiotics and antiseptics for venous ulcer treatment found no evidence that routine use of oral antibiotics improves healing rates. Oral antibiotics are recommended to treat venous ulcers only in cases of suspected cellulitis. Suspected osteomyelitis warrants an evaluation for arterial disease and consideration of intravenous antibiotics to treat the underlying infection.
Hyperbaric oxygen therapy has also been proposed as an adjunctive therapy for chronic wound healing because of potential anti-inflammatory and antibacterial effects, and its benefits in healing diabetic foot ulcers.
However, data to support its use for venous ulcers are limited. Overall, acute ulcers duration of three months or less have a 71 to 80 percent chance of healing, whereas chronic ulcers have only a 22 percent chance of healing after six months of treatment. Removal of necrotic tissue and bacterial burden through debridement has long been used in wound care to enhance healing.
Debridement may be sharp e. However, there are few high-quality studies that directly evaluate the effect of debridement versus no debridement or the superiority of one type of debridement on the rate of venous ulcer healing. Human skin grafting may be used for patients with large or refractory venous ulcers. It is performed with autograft skin or cells taken from another site on the same patient , allograft skin or cells taken from another person , or artificial skin human skin equivalent.
The role of surgery is to reduce venous reflux, hasten healing, and prevent ulcer recurrence. Surgical options for treatment of venous insufficiency include ablation of the saphenous vein; interruption of the perforating veins with subfascial endoscopic surgery; treatment of iliac vein obstruction with stenting; and removal of incompetent superficial veins with phlebectomy, stripping, sclerotherapy, or laser therapy. In one study, ablative superficial venous surgery reduced the rate of venous ulcer recurrence at 12 months by more than one half, compared with compression therapy alone.
Already a member or subscriber? Log in. Collins jefferson. Reprints are not available from the authors. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. Venous ulcer: epidemiology, physiopathology, diagnosis and treatment. Int J Dermatol. Chronic ulcer of the leg: clinical history. Chronic leg ulcers: the impact of venous disease.
J Vasc Surg. Electromagnetic therapy for treating venous leg ulcers. Compression for preventing recurrence of venous ulcers. Briggs M, Nelson EA. Topical agents or dressings for pain in venous leg ulcers. Long-term prognosis for patients with chronic leg ulcers: a prospective cohort study. Eur J Vasc Endovasc Surg. Stockings and the prevention of recurrent venous ulcers. Dermatol Surg. Chronic ulceration of the leg: extent of the problem and provision of care. Ruckley CV.
Socioeconomic impact of chronic venous insufficiency and leg ulcers. Chronic venous insufficiency and venous leg ulceration. J Am Acad Dermatol. Venous ulcers. Clin Dermatol. Leg ulcers.
Clinical Presentation and Diagnosis
Physical examination and chronic lower-extremity ischemia: a critical review. Arch Intern Med. Single-visit venous ulcer assessment clinic: the first year. Br J Surg. Lopez A, Phillips T. The current 'best' practice in the UK is to treat the underlying venous reflux once an ulcer has healed. It is questionable as to whether endovenous treatment should be offered before ulcer healing, as current evidence would not support this approach as standard care. Research from the University of Surrey and funded by the Leg Ulcer Charity is currently looking at the psychological impact of having a leg ulcer, on the relatives and friends of the affected person, and the influence of treatment.
From Wikipedia, the free encyclopedia. Venous ulcer Other names Venous insufficiency ulceration, stasis ulcers, stasis dermatitis, varicose ulcers, ulcus cruris Venous ulcer on the back of the right leg. Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. Journal of Advanced Nursing. JAMA Dermatology. National Institute for Health and Care Excellence. Retrieved June 15, Oxford cases in medicine and surgery. The Case Manager. Retrieved The Cochrane Database of Systematic Reviews.
Retrieved August 25, Retrieved 3 May Cochrane Database of Systematic Reviews. Clin Evid 15 : — Advances in Skin and Wound Care. Cochrane Database Syst Rev. Dermal ulcer healing: Advances in understanding. Paris, France. July Roxburgh's Common Skin Diseases 17th ed. Faculty of Medicine Imperial College London. The Leg Ulcer Charity.
Chronic venous disease and venous leg ulcers: An evidence-based update.
ICD - 10 : I MedlinePlus : Cardiovascular disease vessels I70—I99 , — Arteritis Aortitis Buerger's disease. Carotid artery stenosis Renal artery stenosis.
Aortoiliac occlusive disease Degos disease Erythromelalgia Fibromuscular dysplasia Raynaud's phenomenon. Arteriovenous fistula Arteriovenous malformation Telangiectasia Hereditary hemorrhagic telangiectasia. Cherry hemangioma Halo nevus Spider angioma. Chronic venous insufficiency Chronic cerebrospinal venous insufficiency Superior vena cava syndrome Inferior vena cava syndrome Venous ulcer. Hypertensive heart disease Hypertensive emergency Hypertensive nephropathy Essential hypertension Secondary hypertension Renovascular hypertension Benign hypertension Pulmonary hypertension Systolic hypertension White coat hypertension.
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What are the changes that occur in chronic venous insufficiency?