Ulcers

Question 1

What is the definition of a leg ulcer

Answer 1

Definition of a leg ulcer = any break in the skin of the lower leg above the ankle present more than 4 weeks.

Question 2

Are leg ulcers more commonly arterial or venous?

What two other things cause leg ulcers?

Answer 2

• 60-80% of leg ulcers are venous in nature
• 22% arterial disease
• 9% rheumatoid arthritis
• 5% diabetic
  NB - some can be mixed arterial and venous

Question 3

What questions should you ask in an ulcer history?

Answer 3

• Duration of present ulcer
• Is this their first ulcer?
• Pain
• Disturbing sleep, affecting mobility.
• Medical history – especially ask about h/o varicose veins, DVT, clotting problems, peripheral vascular disease, arterial disease elsewhere, diabetes.

Question 4

How can the position of an ulcer give you a clue about the underlying aetiology?

Answer 4

• Venous – normally develop around the malleoli (gaiter area)
• Diabetic ulcers and arterial ulcers often present on the feet, especially around pressure sites such as the heel, or where shoes rub due to neuropathy
• Don’t forget that skin cancer can present anywhere on the body, including as a non-healing ulcer on the lower leg

Question 5

Give four cutaneous signs of venous disease

Answer 5

Haemosiderin in gaiter area
Distended veins
Ulcer itself is shallow and not punched out
Eczema due to leaky veins

Question 6

Define:

• Atrophie blanche

- Lipodermatosclerosis

Answer 6

Atrophie blanche = white areas of skin after an ulcer

Lipodermatosclerosis = hardening of the subcutaneous fat

Question 7

What are the cuts offs for the different severities of ABPI?

What does this have to do with your treatment?

Answer 7

0.8-1.3 normal
< 0.8 - vascular disease
>1.5 calcification
If patient has a poor ABPI then they shouldn’t receive compression, as any arterial supply left will be blocked.

Question 8

When should you do a wound swab?

Answer 8

ONLY If ulcer increasingly painful/exudative/smelly/enlarging, as a lot of ulcers can look infected when they’re not

Question 9

Give some treatment options for venous ulcer

Answer 9

• Non-adherent dressing
• De-sloughing agent if necessary e.g. hydrogel/ honey
• 4 layer compression bandaging – may need to increase compression gradually if pain a problem
• Leg elevation

Question 10

Describe some features of the four layer bandaging system

Answer 10

• Graduated compression
• 40mmHg at ankle, 25mmHg below knee
• Latex/ rubber free if possible
• Applied by a trained nurse
• Non-adherent dressing
• Leg padded to a cone shape
• Changed weekly, or as required
• AIM TO HEAL ULCERS BY 12 WEEKS

Question 11

What is honey and maggots used for in ulcers?

Answer 11

Honey can be used as a debriding agent to remove slough.
Maggots – very effective debriding agent; contained within a bag so don’t escape; once they’re done their job they are incinerated. They are very effective but very expensive.

Question 12

What is zinc paste used for in treating ulcers?

Answer 12

Used as a barrier, as maggots and other debriding agents release enzyme which can macerate the surrounding skin

Question 13

What does the patient still require once the ulcer is healed?

Answer 13

Once ulcer is healed, have to use compression stockings

• 60% recurrence rate at 1 year if no prevention
• Class 1(weak) to class 3 (strong).
• Most patients manage class 2 stockings

Question 14

Give some clinical features of arterial ulcers

Answer 14

Arterial ulcers – often deep, punched out, on foot, in pressure areas. Leg tends to be pale and hairless.