Leg Ulcers

Question 1

Chronic leg ulcer definition

Answer 1

Open lesion
Between knee & ankle
Remains unsealed for 4 weeks

Question 2

Chronic leg ulcer aetiology

Answer 2

• Venous disease - venous blood stasis (most common)
• Arterial disease - PVD (second most common)
• Diabetes - poor wound healing (third most common)

Other
- Vasculitis
- Malignancy (of skin)
- Inflammatory disease (of skin)
- Pyoderma gangrenosum with underlying autoimmune

Question 3

Venous ulcer pathophysiology

Answer 3

1. Elevation of venous pressure in the legs e.g. by abdominal obesity that resists venous return from the legs
2. Veins dilate and valves become incompetent, varicose veins develop
3. The increased hydrostatic pressure in the vessels results in red blood cell leakage into the tissue
4. This causes swelling, haemosiderin, pigmentation and inflammation (due to breakdown products) i.e. venous (stasis) dermatitis
5. The skin cannot heal well due to poor blood supply, so begins to break down
6. Venous insufficiency also acts as a risk factor for DVT/PE

Question 4

Arterial ulcer pathophysiology

Answer 4

Caused by insufficient blood supply due to peripheral vascular disease

Question 5

Summarise the appearance of:
- venous
- arterial
- vasculitic
- pyodrema gangreosum
- diabetic
… ulcers

Answer 5

Venous
- superficial, exudative, warm
- usually around the medial malleolus/ gaiter area
- venous insufficiency signs e.g. varicose veins

Arterial
- deep, ‘punched out’,
- usually on the foot
- PVD signs e.g. intermittent claudication
- pain worse at night, with elevation

Vasculitis - multiple, necrotic sores
Pyoderma g. - dusky purple raised border, enlarges rapidly
Diabetic - punched out ulcer on pressure site

Question 6

Signs of venous insufficiency

Answer 6

• ankle swelling,
• varicose veins,
• haemosiderin deposition,
• venous eczema,
• lipodermatosclerosis (later stage)

Question 7

Signs of arterial disease/ peripheral vascular disease

Answer 7

• intermittent claudication
• absent peripheral pulses
• cold, white and shiny skin

Question 8

Leg ulcer investigations

Answer 8

General
- Assess ulcer: record position and measure surface area
- Bloods: FBC, LFTs, U+Es, CRP

Arterial vs venous
- ABPI: to establish if there is arterial disease (1st line)
- Duplex scan: only if indicated to rule out arterial disease

Other
- Biopsy: only if suspect malignancy
- Wound swab: only if suspect infection of ulcer
- Patch testing: only if ulcer not improving & suspect allergy to ulcer treatment

Question 9

What would make you want to take a swab of a leg ulcer

Answer 9

If ulcer is increasingly painful/exudate/malodour/enlarging (suspect infection)

Question 10

What is a ABPI and what results would indicate arterial ulcer/ PVD

Answer 10

ABPI
- ankle/ brachial pressure index
- Highest ankle systolic: Highest brachial systolic ratio

Results
- if 1 then normal, no PVD
- If <0.8 or >1.5 (calcification) then PVD

Question 11

How would you describe lipodermatosclerosis

Answer 11

• Woody tethered skin
• Reverse champagne bottle leg

Question 12

What is slough

Answer 12

Debris & dead bacteria

Question 13

Arterial ulcer treatment

Answer 13

reducing modifiable risk factors - treat hypertension, prescribe statin, prescribe antiplatelet

Question 14

Venous ulcer treatment

Answer 14

• 4 layer compression bandaging followed by compression stockings +/-
• Pain control
• De-sloughing agents
• Leg elevation
• Non-adherent dressings

Question 15

Name 4 other treatment options for difficult venous leg ulcers

Answer 15

• Sharp debridement - with scalpel or scissors
• Biological - larvae therapy
• Surgical - under general anaethetic
• Autolytic - the use of dressings to create moist wound (hydrogen, honey)

Question 16

Ulcer complications

Answer 16

Infection
Contact allergy
Malignant transformation
DVT (from venous ulcer)