Leg Ulcers (Arterial & Venous)
Just the mention of an ulcer is a concern to patients. An ulcer is an area that has lost the covering layer of skin so that the tissues beneath the skin are exposed. While this explanation is simple, it does not say anything about the cause of the ulcer or how it will respond to treatment.
First we need to understand that there is an important distinction between an ulcer and a scrape or graze on the leg. In the case of a graze, only the superficial layers of the skin are lost although this can be deep enough to cause bleeding. In an ulcer the whole thickness of the skin is lost and there are no skin cells in the wound. This difference has important implications for healing. In the case of a graze, healing can take place over the whole graze because there are still skin cells over the whole area. Healing is quick, usually just a matter of a few days, because of these cells. In an ulcer the only way skin cells can bridge (or heal over) the ulcer is for the cells to grow in from the edges. This is a much slower process even in perfect conditions.
Leg ulcers occur in association with a range of disease processes but most commonly with problems of blood circulation due to arterial disease or venous disease.
Leg ulcers may be acute or chronic.
- Acute ulcers are those that follow the normal phases of healing in that they usually show signs of healing in less than 4 weeks and include traumatic and postoperative wounds.
- Chronic ulcers are those that persist for longer than 4 weeks and the cause is often more complex.
Causes and risk factors for leg ulcers
Ulcers may be caused by injury or pressure. They may also be caused by bacterial infection and cellulitis, which is an infection of the skin and its underlying connective tissues.
Chronic leg ulcers may also be due to skin cancer, which can be diagnosed by a skin biopsy of a suspicious lesion. There are also many less common causes of ulcers including systemic diseases such as: scleroderma (hardening of the skin and tissue), vasculitis (inflammation in a blood vessel), and various other skin conditions.
Chronic leg ulceration most commonly occurs after a minor injury in association with:
- Chronic venous insufficiency
- Chronic arterial insufficiency
Individuals who are at most risk for developing leg ulcers are those with any of the following:
Venous insufficiency. Venous insufficiency refers to improper functioning of the one-way valves in the veins. Veins drain blood from the feet and lower legs uphill to the heart. Two mechanisms assist this uphill flow, the calf muscle pump which pushes blood uphill toward the heart during exercise, and the one-way valves which prevent the flow of blood back downhill. There may be reflux through the valves, obstruction of the veins and/or impaired calf pumping action that results in pooling of blood around the lower part of the leg to just below the ankle. The increased venous pressure causes deposits of fibrin (a protein formed in our body that is important in clotting) around the capillaries. These fibrin deposits then act as a barrier to the flow of oxygen and nutrients to muscle and skin tissue. The death of tissue cells leads to the ulceration. This causes the destruction of the capillaries in the subcutaneous and fatty tissue leaving the skin and fibrous layer that surrounds the leg stuck to the underlying bone. The death of these tissues leads to ulceration.
Arterial insufficiency. Arterial insufficiency refers to poor blood circulation to the lower leg and foot and is most often due to atherosclerosis. In atherosclerosis the arteries become narrowed from deposits of fatty substances in the arterial vessel walls, often due to high levels of cholesterol and aggravated by smoking and high blood pressure (hypertension). The arteries fail to deliver oxygen and nutrients to the leg and foot resulting in tissue breakdown.
Diabetes. Diabetic (neurotrophic) ulcers are caused by the combination of arterial blockage and nerve damage, neurotrophic meaning that the tissue is dependent on nerves to remind you of pain, pressure and to protect your skin. The nerve damage, or sensory neuropathy, reduces awareness of pressure, heat, pain or injury such as a cut. Rubbing and pressure on the foot goes unnoticed and causes damage to the skin and subsequently a neuropathic ulceration develops. Because you cannot feel your feet normally, you must visually inspect all the skin of your feet two or three times each day.
Certain conditions have been linked with the development of venous and arterial leg ulcers.
The importance of maintaining good venous pressure is described here.
Diabetic ulcers are more likely if diabetes is not well controlled by diet and/or medication. Ulcers are also more likely if there is poor care of the feet, badly fitting shoes and continued smoking. If you have diabetes and most especially if you have a diabetic neuropathy of your feet, do not ever trim your own toenails with a pocket knife or allow someone to cut them with a pocket knife. You should see a foot specialist (podiatrist) on a regular basis to keep your toenails properly trimmed or a properly trained family member. A toenail that rubs or cuts into the toe beside it can be the start of serious problems. Again, you should visually check your feet daily for any cuts or abrasions or skin changes and seek medical attention if any are observed.
Signs and symptoms of leg ulcers
It needs first to be emphasized that if you have any of the signs or symptoms of leg ulcers or suspect that you have an ulceration, seek medical attention.
The features of venous and arterial ulcers differ somewhat but usually will have the following characteristics.
Characteristics of venous ulcers include:
- Located below the knee and most often on the inner part of the ankles but can be anywhere around the ankles
- Relatively painless unless infected
- Associated with aching, swollen lower legs that feel more comfortable when elevated
- Surrounded by mottled brown or black staining and/or dry, itchy and reddened skin (eczema)
- Usually associated with varicose veins due to incompetence of the superficial venous system
- May be associated with lipodermatosclerosis, which is loss of tissue under the skin and in which the lower part of the leg is hardened. This skin is brown because of leakage of the capillaries of protein and red blood cells (hemosiderin) that stain the tissue brown.
- Often associated with swelling, which may be caused by local inflammation. Chronic (constant or long lasting) inflammation destroys underlying lymphatic vessels, causing lymphedema and increased pressure in the lower leg.
- Thickened skin, scaliness, tiny rough bumps on the lower legs and feet, fissuring, oozing
Characteristics of arterial ulcers include:
- Usually found on the lateral side of the ankles, feet, heels, toes but not always just lateral ankle
- Frequently painful, particularly at night in bed or when the legs are at rest and elevated. This pain is relieved when the legs are lowered with feet on the floor and it is postulated that gravity causes more blood to flow into the legs, but we do not really know. Sufferers may find they will hang their legs over the side of the bed at night, or sit or stand for relief. (Rest pain)
- The borders of the ulcer appear as though they have been ‘punched out’ and have a gray base
- Associated with cold white or bluish, shiny -skinned feet
- There may be cramp-like pains in the legs when walking, known as intermittent claudication, as the leg muscles do not receive enough oxygenated blood to function properly. Resting just a few minutes will relieve this pain.
- Doppler arterial testing by a vascular specialist to measure the ankle to brachial index and toe to brachial index. The level of severity can be determined by these pressures.
Characteristics of diabetic ulcers include:
Diabetic ulcers have similar characteristics to arterial ulcers but are more notably located over pressure points such as heels or between toes or anywhere on the bottom of the feet where the bones may protrude and rub on wrinkles in socks or improper fitting shoes. In response to pressure, the skin increases in thickness (or forms a callus) but with a minor injury breaks down and thus an ulcer is formed.
Infected ulcers may have surrounding tender redness, warmth and swelling (cellulitis).
How are leg ulcers diagnosed?
A visit to your doctor will most likely result in referral to a vascular specialist. Here an extensive medical and family history will be obtained and evaluated. A physical examination will be performed and based on whether the findings indicate arterial ulceration, venous ulceration or a combination, non-invasive vascular studies will be obtained. This can be a leg arterial study to test the quality of flows in your arteries or a venous duplex Doppler to check the blood flow in your veins. These studies are obtained in the doctor's office and the findings will be discussed with you at the conclusion of testing along with the beginnings of a treatment plan.
If your vascular specialist determines that further testing such as x-rays, MRA or CTA scan can be of added benefit to determine the best care this, too, will be discussed and planned.
The goals of treatment are to:
- Relieve the pain
- Speed recovery
- Heal the wound
But before commencing treatment of an ulcer, it is essential that the cause is correctly diagnosed. At the Vascular Center of Wichita Falls, each patient is an important individual and, therefore, each plan of treatment is individualized based on the diagnostic findings, patient's health, medical condition and ability to care for the wound.
Treatment options for all ulcers may include:
- Antibiotics if an infection is present
- Antiplatelet (or anti-clotting) medications to prevent a blood clot
- Topical wound care therapy
- Compression if appropriate
Venous ulcer treatment
Venous leg ulcers, in the absence of arterial disease, are usually treated with exercise, proper elevation at rest, and compression. Compression must not be used if there is significant arterial disease as it will aggravate an already inadequate blood flow. Sclerotherapy or endovascular laser treatment of superficial and perforator leg veins may also be the preferred treatment.
If findings on diagnostic testing indicate enough severity of arterial disease, a recommendation for consultation with a vascular surgeon may be made for consideration to have surgery to relieve the narrowing of the arteries. This procedure is known as revascularization and is usually quite successful.
It is also very important to treat underlying diseases such as diabetes and to stop smoking. Venous ulcers are treated with compression of the leg to minimize swelling (edema). Compression therapy can include wearing compression stockings, multi-layer compression wraps or wrapping with short-stretch bandages (an ACE is a long-stretch bandage) or dressing from the toes to the area below the knee. The type of compression treatment prescribed is determined by the vascular specialist based on the characteristics of the ulcer. Appropriate wrapping of bandages should be taught to the patient because if this is not done correctly they can actually cause further problems by cutting off the blood flow that is present.
There are various types of dressings prescribed for ulcers and referral to a wound center may be appropriate.
Arterial ulcer treatments vary depending on the severity of the arterial disease. Non-invasive vascular tests provide the physician with the diagnostic tools to assess the potential for wound healing. Depending on the patient's condition, the physician may recommend invasive testing such as arteriograms in the hospital, endovascular therapy or bypass surgery to restore circulation to the affected leg.
The goals for arterial ulcer treatment include:
- Providing adequate protection of the surface of the skin
- Preventing new ulcers
- Removing contact irritation to the existing ulcer
- Monitoring signs and symptoms of infection that may involve the soft tissues or bone
- Revascularization of the leg if needed
The primary goal of the treatment of arterial ulcers is to increase circulation to the area, either surgically or medically. Surgical options range from revascularization in order to restore normal blood flow to amputation and rehabilitation in extreme cases. As for non-surgical measures, modifying contributing factors can slow or stop the progression of the local ischemia. Additionally, there are boots and pumps available to increase perfusion to the affected limb. Additionally, there are boots and pumps availble to improve blood flow to the affected limb but the use of these have limited effect.
Ischemic wounds differ from other severe wounds in that the wound environment should be as dry as possible to decrease the risk of infection. Your vascular specialist will advise you on how to take direct care of the ulcerated area and write any needed prescriptions. In some extreme cases, referral to a wound center may be appropriate.
Topical antibiotic ointments, such as triple antibiotic, should be used sparingly as they can actually be toxic to cells. The wisest actions on the part of the patient is to carefully follow all instructions and treatment recommendations of their doctor or wound specialist.
Diabetic ulcer treatment
Treatment for diabetic (neurotrophic) ulcers includes avoiding pressure to the ulcerated area, special diabetic shoes and possibly limited weight-bearing on the affected leg. Regular debridement (the removal of infected tissue) is usually necessary before a diabetic ulcer can heal. Frequently, special shoes or orthotic devices must be worn. A podiatrist is usually involved.
How you care for the skin can help or can make the area worse. You should always talk with your doctor or vascular specialist before using any creams or lotions or antibiotic ointments. Again, never cut your own toenails with a pocket knife or trim your own toenails or allow someone else to trim them for you unless they have been trained in how to do this.
Controlling risk factors can help you prevent ulcers from developing or getting worse. Follow the recommendations of your vascular specialist who will individualize your care, but here are some common and sensible ways to reduce your risk factors and promote healing of ulcers and prevent new ulcers or old ulcers from recurring:
- Quit smoking
- Manage your blood pressure
- Control your blood cholesterol and triglyceride levels by making dietary changes and taking medications as prescribed
- Limit your intake of salt (sodium)
- Manage your diabetes and other health conditions
- Develop a true exercise program for both arterial and venous problems. For venous problems walk and exercise daily to keep the calf muscle pump working properly.
- Lose weight if you are overweight. If you are significantly overweight, swelling improvement will be limited until you have lost weight.
- Ask your doctor about aspirin therapy or other medications to prevent blood clots.
- Be very careful not to injure your legs.
- Check your feet and legs regularly by looking for cracks, sores or changes in color. Moisturize after bathing.
- Wear comfortable well-fitting shoes and socks. Avoid socks with a tight garter or cuff. Check the inside of shoes for small stones or rough patches before you put them on. You may require special shoes, such as diabetic shoes.
- If you have to stand for more than a few minutes, try to vary your stance as much as possible by shifting weight to different areas of your feet.
- When sitting, wiggle your toes, pump your feet up and down and take frequent walks.
- If your legs are swollen, elevate you legs higher than your heart as often as possible but for at least one hour a couple of times daily. Water and blood run downhill. A swollen leg does not heal.
- Avoid extremes of temperature such as hot baths or sitting close to a heater unless you have checked the temperature with your fingers. Keep cold feet warm with socks (SmartWool brand are great), wearslippers and never go barefoot even in the house.
- Consult a podiatrist to remove callus or hard skin.
- Only wear compression stockings prescribed by your doctor. The compression could be too little or too strong. This is particularly important for post-thrombotic syndrome, leg swelling or discomfort and for long-distance flights or long car trips.
- Have vascular ultrasound assessment and consult a vascular specialist to determine whether any vein treatment should be carried out to improve blood flow back to your heart.
- Have the arteries checked that carry blood to your feet to be sure they are adequate for healing.
We hope the information on these pages is both informative and helpful, but it is intended for education only. Please do note that no web site, no matter how much information is shared, can replace a consultation with your doctor and a vascular specialist. Medical technology and treatment are continually improving and evolving so before making any decision on treatment, it is always advisable to see your doctor first for a comprehensive evaluation of your vascular disease and other medical conditions.
At the Vascular Center of Wichita Falls, we work closely with your other physicians. If you have concerns about your arteries or veins, contact us. A referral is not necessary to make an appointment.