An ulcer, as it relates to skin, is defined as a discontinuity in the normal layers that make up the skin, thus leaving a void. There are different types of ulcers but this discussion will be limited to venous stasis ulcers.
It is estimated that venous stasis ulcers affect 500-600,000 people in the United States every year and it is by far the most common type of leg ulcer seen.
This type of ulcer accounts for the loss of 2 million working days and incurs treatment costs closing in on $3 billion dollars per year in the USA.
These types of ulcers are found on the inner part of the lower leg usually just above the ankle. They can occur either on one or both legs and each leg may have more than one ulceration.
SYMPTOMS- may include mild to severe edema of the foot, ankle and lower leg as well as sensations of fatigue and heaviness with burning or itching. Simple elevation of the leg for an hour at at time will bring much pain relief to most people. There may also be a rash, redness, brown discoloration which is known as hemosiderin deposits which is nothing more then blood seeping into the skin and staining it.
APPEARANCE- The ulcer usually presents itself as an open sore in an area that already typically exhibits a red to brown discoloration that has probably been present for some time. The area will also be swollen. Prior to the formation of the ulceration the skin may have also been somewhat flaky and itchy as well. This pre-ulceration condition is known as stasis dermatitis which is an eczema of the skin as a result of blood perfusing through and settling into the layers of skin, breaking down and depositing hemosiderin and melanin, as a result of the venous system’s inability to adequately pump it up to the heart.
The base of the ulcer is usually red, but overlying the base there may be a white to yellow tissue that is known as fibrous tissue which is basically a type of scar tissue that does not promote healing. There may be a clear to yellow drainage coming from the wound. This can occur without the ulcer being infected, however, if the wound is infected there generally will be larger amounts of drainage coming from the wound and the surrounding area will be much more red in color than normal (normal including those with stasis dermatitis). Antibiotics are not routinely administered unless the wound is grossly infected. What may appear as an infection to the layperson will be nothing more than inflammation to the experienced doctor.
Note the picture below. There are actually two small venous stasis ulcers present, noted by the blue arrows. Also evident is yellow fibrous tissue.
COMPRESSION- venous stasis ulcers are treated through compression of the affected leg to minimize swelling. If you do not eliminate the constant swelling you dramatically reduce the likelihood of closing the wound. People with varicose veins will notice that their feet and ankles are generally normal in size in the morning only to get progressively more swollen as the day goes on. For this reason it is important to have a dressing change with fresh compression in the morning in an effort to not allow the foot and leg to swell during the course of the day. As a side note, many people, particularly the elderly will develop venous stasis ulcers from nothing more than sitting all day with their feet in a dependent position. This coupled by the fact that depending on the type of chair they are sitting on, they may be cutting off the return circulation of the veins behind the thigh thus further exacerbating the problem. Add to this the fact that many elderly also have poor arterial circulation, their skin will become very thin (onion like) and the slightest trauma to the area, including just scratching the area will precipitate the formation of an ulcer.
Compression of the affected limb may include compression stockings, ace bandage or similar multilayer compression wraps or even an unna boot which is a compression dressing containing zinc oxide, calamine lotion, glycerin and gelatin that not only reduces swelling but also helps heal the ulcer. It is very important to note that many people with venous stasis ulcers also suffer from arterial insufficiency. In those individuals excessive compression therapy is not indicated as it will further impede blood flow down to the foot.
Although compression therapy has been the gold standard, there are some individuals that cannot tolerate compression over the ulcer; it just hurts too much. In recent years a drug call pentoxifylline (Trental) has been used with a reasonable amount of success. Pentoxifylline's original indication was for arterial insufficiency or poor blood flow down to the feet. It is thought that the drug works in a couple of ways. One, it improves the circulation down to the feet which in essence would improve the ability of the body to heal itself by bringing more nutrients to the site of the ulcer. Two, it may also improve the actual wound environment of the stasis ulcer so that it will heal quicker.
This therapy may be combined with compression therapy or may be used alone in those individuals who cannot tolerate compression. In studies it was found that a higher than usual dosage of pentoxifylline was more effective in closing this type of ulcer.
CARE OF THE WOUND- the ulcer itself generally has to be treated in an effort to remove all devitalized tissue and to promote formation of healthy granulating tissue. Debridement or removal of this dead tissue may be done in a couple of different ways. The most common is through sharp debridement where your doctor takes a scalpel and scrapes away all dead tissue within the ulcer and immediately surrounding the wound. The problem with this is that it can be a painful procedure and at times may have to be done under local anesthesia.
Other techniques include mechanical debridement using modalities such as wet to dry dressings , hydrotherapy and wound irrigation where the action of water against the wound helps remove the dead tissue. We also have available to us what is known as enzymatic debridment where through the use of topical ointments we can remove dead tissue. In this day and age we now have wound dressings which also have the capability of help remove debris from the wound.
Dead tissue has to be removed for two reasons, one it harbors bacteria so if the wound is already infected it helps clear up the infection and if the wound is not yet infected it greatly reduces the possibility of infection. Secondly, healthy tissue cannot form where there is an abundance of dead tissue so healing will be delayed.
Of all the types of debridement methods available I feel the use of the scalpel is the most effective. It allows the doctor to remove exactly what he wants and does so much more effectively than other methods. The only time an ulcer does not have to be debrided is when a dry scab (eschar) has formed over the ulcer. The eschar acts as a protective barrier and greatly reduces the chance of infection.
The type of dressing that goes under the compression dressing will be at the discretion of your doctor. One thing there is no shortage of these days are wound care dressings. The type used on your wound will be the one your doctor has had the most success with.
Treating an ulcer is not like treating a “cut”. You have to be very careful of what you place on the wound. An ulcer is a result of devitalization to the tissue and applying certain topical ointments, creams and liquids may actually do more damage. Things like alcohol, witch hazel, betadine amongst others will actually make the wound worse.
Venous stasis ulcers may take a long time to heal. Healing rates can be poor with up to 50 percent of venous ulcers open and unhealed for nine months or longer. Factors such as the degree of venous insufficiency, the size of the ulcer, the severity of the surrounding stasis dermatitis, a history of phlebitis, smoking, obesity and not properly following your doctor’s orders will all prolong the healing time. In certain instances ulcers that are taking excessively long to heal should be biopsied to rule out malignancy or vasculitis.
Once healed, if the underlying problem is not resolved or at least controlled, there is a very high incidence of recurrence. Venous stasis ulcer recurrence rates occur in one third of treated individuals with some experiencing four or more episodes of ulceration. This would include regular use of compression stockings as well as lotions to keep the skin hydrated. Additionally, accompanying disease states and bad habits also have to be resolved.
Other things that can be done to avoid venous stasis ulcers in those predisposed to the problem include: