Leg ulcer

What is a leg ulcer?

A leg ulcer is a loss of full-thickness skin on the leg or foot due to any cause. Leg ulcer occurs in association with a variety of disease processes, most commonly with arterial, vascular or neuropathic diseases A leg ulcer can be acute or chronic.

• An acute ulcer is sometimes defined as one that follows the typical phases of healing; It is expected to show signs of healing in less than four weeks and includes traumatic and postoperative wounds.
• A chronic ulcer persists for more than 4 weeks and often has complex and poorly understood origins.

Who gets leg ulceration?

Chronic leg ulceration affects approximately 1% in the middle-aged and elderly population. It most commonly occurs after a minor injury in association with:

• Chronic venous failure (45-80%)

• Chronic arterial insufficiency (5-20%)

• Diabetes (15-25%)

• Hypertension

Chronic leg ulcers it can also be due to the skin Cancer, which can be diagnosed by a skin biopsy off the edge of a suspect injury. There are also many less common causes of ulcers including systemic diseases such as systemic sclerosis, vasculitis and various skin conditions especially pyoderma gangrenous

What Causes Leg Ulcers?

An ulcer can be caused by an injury or pressure, such as a cast or ski boot that doesn't fit well. They can also be caused by bacterial infection, especially impetigo, ecthyma and cellulitis and less frequently tropical ulcer, tuberculosis or leprosy.

Venous insufficiency

Venous insufficiency refers to the improper functioning of the one-way valves in the veins. Veins drain blood from the feet and legs to the heart. Two mechanisms assist this upward flow, the calf muscle pump that pushes blood toward the heart during exercise, and the one-way valves that prevent downward flow of blood. There may be backflow through the valves, blocked veins, and / or the pumping action of the damaged calf causing blood to pool around the lower leg just below the ankle. Increased venous pressure causes fibrin deposits around capillaries, which then act as a barrier to the flow of oxygen and nutrients to muscle and skin tissue. The death of tissue cells leads to ulceration.

Arterial insufficiency

Arterial insufficiency refers to poor blood circulation in the lower leg and foot and is most often due to atherosclerosis. In atherosclerosis, the arteries are narrowed by deposits of fatty substances on the walls of the arterial vessels, often due to high levels of circulation. cholesterol and aggravated by smoking and high blood pressure (hypertension). The arteries cannot supply oxygen and nutrients to the legs and feet, which causes the breakdown of tissues.

Diabetes

Diabetic ulcers are caused by the combination of arteries occlusion and nerve damage. Although diabetic ulcers can occur on other parts of the body, they are most common on the foot. Nerve or sensory damage neuropathy Reduces awareness of pressure, heat or injury. Rubbing and pressure on the foot go unnoticed, causing skin damage and "neuropathic" ulceration.

See more about the differential diagnosis of leg ulcers.

Who is at risk for leg ulcers?

Certain conditions have been linked to the development of venous and arterial leg ulcers.

Venous ulcer

• Varicose veins
• History of leg swelling.
• History of blood clots in deep veins, that is, deep veins. thrombosis (DVT) causing post-thrombotic syndrome (in 5% of cases)
• Sitting or standing for long periods
• Hypertension
• Multiple pregnancies
• Previous surgery
• Fractures or injuries
• Obesity
• Increasing age and immobility

Arterial ulcer

• Diabetes
• Of smoking
• High blood fat / cholesterol
• Hypertension
• Renal failure
• Obesity
• Rheumatoid arthritis
• Coagulation and circulation disorders.
• History of heart disease. cerebrovascular illness or peripheral vascular disease

A diabetic ulcer is more likely if diabetes is not well controlled with diet and / or medications. Ulceration is also more likely if there is poor foot care, poorly fitting shoes, and continuous smoking.

What are the signs and symptoms of leg ulcers?

The characteristics of venous and arterial ulcers differ somewhat.

Venous ulcer

The characteristics of a venous ulcer include:

• Located below the knee, most often on the inside of the ankles.
• Relatively painless unless infected.
• Associated with pain in the swollen lower legs that feel more comfortable when elevated.
• Surrounded by mottled brown or black patches and / or dry, itchy and reddened skin (gravitational or venous eczema)
• It can be associated with varicose veins due to incompetence of the superficial venous system (50%).
• May be associated with lipodermatosclerosis, in which the lower leg is hardened
• Often associated with swelling, which can be caused by local inflammation. Chronic inflammation destroys the underlying lymphatic vessels, causing lymphedema. This increases the pressure on the lower leg.
• Thickened skin, hyperkeratosis (peeling), papillomatosis (small rough bumps on the lower legs and feet), fissureoozing

Arterial ulcer

Characteristics of an arterial ulcer include:

• It is usually found on the feet, heels, or toes.
• Often 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 the feet on the floor, as gravity causes more blood to flow to the legs.
• The edges of the ulcer appear to have been "perforated."
• It is associated with cold white or bluish, shiny feet.
• There may be cramp-like pains in the legs when walking, known as intermittent claudicationas the leg muscles do not receive enough oxygenated blood to function properly. Rest will ease this pain.
• The clinical evaluation measures the ankle-brachial pressure index (ABPI) by using a Doppler probe to measure the pressure in the arm and ankle. The normal value of 0.92 to 1.3. If the ABPI is less than 0.9, arterial disease is likely. Levels less than 0.5 indicate severe arterial disease.

See more images of leg ulcers.

Diabetic ulcer

A diabetic ulcer has characteristics similar to an arterial ulcer, but is most notably located on pressure points such as the heels, the tips of the toes, between the toes, or anywhere the bones may protrude and rub. against sheets, socks or shoes. In response to pressure, the skin thickens (calluses) but with a minor injury, it breaks and ulcerates.

Infected ulcer

An infected ulcer characteristically has a yellow surface Cortex or green / yellow pus and may smell unpleasant. There may be sensitive redness, warmth and swelling (cellulite).

What is the treatment for leg ulcers?

Whenever possible, treatment aims to reverse the factors that have caused the ulcer. Since an ulcer is often the result of arterial and venous disease, a careful evaluation is needed first.

Venous leg ulcer, in the absence of arterial disease, is usually treated with exercise, elevation at rest, and compression. Compression should not be used if there is significant arterial disease, as it will aggravate an inadequate blood supply. Surgery, ultrasoundguided or endovascular sclerotherapy To be Treatment of superficial and perforating leg veins can also help, particularly if the deep venous system is intact. Venous return-assisted compression devices may be of additional benefit.

Patients with arterial leg ulcers should also be evaluated by a vascular surgeon, as they may require surgery to relieve narrowing of the arteries. Revascularization is particularly important if the ABPI is less than 0.5.

It is also very important to treat underlying diseases such as diabetes and to stop smoking.

Clean the wound

No matter what the cause of the ulcer is, meticulous skin care and wound cleaning are essential. Removal of surface contamination and dead tissue is known as debridement. Surgical debridement or medical debridement can be used using wet and dry dressings and ointments. Worms and larval therapy are occasionally recommended. Debridement turns the chronic wound into an acute wound so that it can progress through the normal stages of healing. Special irrigation solutions contain surfactants and antimicrobial agents to remove biofilm and it can improve healing.

Treat tissue infection

Antibiotics are not necessary unless there is a bacterial infection in the tissues. This is likely if the ulcer becomes more painful and / or the surrounding skin becomes red, hot, or inflamed (cellulite). Cellulite can also cause fever and disease. It must be treated with oral antibiotics such as flucloxacillin; the choice will depend on the cause organism. Current it is better to avoid antibiotics because their use can result in increased resistance to antibiotics and allergy.

Long-standing leg ulcers are frequently colonized by micro-organisms in a biofilm Biofilm can be composed of bacteria, fungi or other organisms, which are embedded and attached to the underlying wound. Biofilm may contribute to the failure of the ulcer to heal, but at this time the best way to diagnose and control The biofilm is unknown. Organisms are protected from the effect of conventional antibiotics; the unnecessary prescription of antibiotics can actually select for more resistant organisms.

Dress the wound

There is a wide range of specialized dressings available to help with the various stages of wound healing. These are classified as non-absorbent, absorbent, debridement, self-adhesive and others. Consult an expert in wound healing to determine the most suitable one; this will depend on the site and type of ulcer, personal preference and cost.

Dressings are generally occlusive How ulcers heal best in a humid environment. If the ulcer is clean and dry, the occlusive dressings are usually changed weekly; More frequent changes are avoided as dressing changes remove healthy cells and debris. Contaminated or watery wounds may require more frequent dressing changes, sometimes every few hours. Honey dressings can be helpful.

Surgical management

Surgery may be considered if the ulcer does not heal with conservative measures, particularly if it is very large or painful. First, the state of the venous and arterial systems must be evaluated, the infection eliminated, and the underlying associated diseases controlled, such as diabetes, thrombophilia (tendency to blood clots) or malnutrition.

Clean chronic ulcers can be treated with various types of skin grafts. The wound needs to be carefully prepared. A shaving procedure to remove the surrounding lipodermatosclerosis may be worthwhile before applying the skin graft.

Accelerate wound healing.

Wound healing requires adequate protein, iron, vitamin C, and zinc. Supplements may be prescribed if they are deficient in the diet.

New products exist to aid wound healing, but they require more research to determine their effectiveness. These include:

• Growth factors and cytokines
• Hyperbaric oxygen to increase the oxygen tension in the tissues.
• Skin graft substitutes (bioengineered skin)
• Connective tissue matrix
• Expanded epidermis
• Epidermal Mother cells
• HOLIDAYS. (vacuum assisted closing) device
• Worm debridement therapy
• Simvastatin

In some patients, the ulcers do not heal on their own and require surgery. The procedure generally involves taking skin from another part of the patient's body and placing it over the ulcer (skin graft). Despite this procedure, it is not uncommon for the ulcer to reappear.

Compression

Compression therapy is an important part of treating venous leg ulcers and chronic lower leg inflammation. Compression results in 40-70% healing from chronic venous ulcers in 12 weeks. Compression therapy is accomplished through the use of a stocking or bandage that is wrapped from the toes or feet to the area below the knee. This external pressure on the leg helps to heal the ulcer by increasing the action of the calf muscle pump and reducing the swelling in the leg. Compression is not used if the ABPI is below 0.8.

There are several options available to achieve compression.

• Multiple layers of a bandage (3- or 4-layer bandage compression system)
• Tubular shaped bandage
• Elastic graduated compression stockings (stockings)
• Unna boot (gauze bandage impregnated with zinc oxide)

Can leg ulcers be prevented?

To prevent and promote healing of ulcers:

• Avoid injury, especially when pushing a grocery cart. Consider shin splints.
• Walk and exercise for at least an hour a day to keep your calf muscle pump working properly.
• Lose weight if you are overweight.
• Stop smoking.
• Check your feet and legs regularly. Look for cracks, sores, or color changes. Hydrate after bathing.
• Wear comfortable, well-fitting shoes and socks. Avoid socks with a tight garter or cuff. Check the inside of your shoes for small stones or rough patches before putting them on.
• If you have to stand for more than a few minutes, try to vary your posture as much as possible.
• When sitting, wiggle your toes, wiggle your feet up and down, and walk frequently.
• Avoid sitting cross-legged. Place your feet on a cushioned stool to reduce swelling.
• Avoid extreme temperatures like hot baths or sitting near a heater. Keep cold feet warm with socks and slippers.
• See a podiatrist or podiatrist to remove a callus or hard skin.
• Wear at least Grade 2 support stockings (compression stockings) if your doctor has recommended it. This is particularly important for post-thrombotic syndrome, leg swelling or discomfort, and for long-haul flights.
• Get a vascular ultrasound evaluation and see a vascular surgeon to determine if any venous treatment should be done.

• Horse chestnut extract appears to be beneficial for at least some patients with venous disease.