Leg Ulcers (Arterial & Venous) | Vascular Center of Wichita Falls

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Vascular Center of Wichita Falls

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Leg Ulcers (Arterial & Venous)

Overview

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.

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:

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.

Venous Ulcers  

Arterial Ulcers  

  • Varicose veins
  • History of leg swelling
  • History of blood clots in deep veins (deep vein thrombosis--DVT) causing post-thrombotic syndrome
  • Sitting or standing for long periods
  • High blood pressure
  • Multiple pregnancies
  • Previous surgery
  • Fractures or injuries
  • Obesity
  • Increasing age and immobility
  • Clotting and circulatory disorders
  • Diabetes
  • Smoking
  • High blood fat/cholesterol
  • High blood pressure
  • Renal failure
  • Obesity
  • Collagen-vascular disorders
  • Clotting and circulation disorders
  • History of heart disease, cerebrovascular disease or peripheral vascular disease

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.

Venous ulcers

Characteristics of venous ulcers include:

Arterial ulcers

Characteristics of arterial ulcers include:

Diabetic ulcers

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.

Treatment

The goals of treatment are to:

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:

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 treatment

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:

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. 

Prevention

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:

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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.

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