Venous & Arterial Ulcers

Question 1

What is the definition of an ulcer?

Answer 1

ulcers are abnormal breaks in the skin or mucous membranes

Question 2

What are the majority of lower limb ulcers caused by?

What are more rare causes of lower limb ulcers?

Answer 2

• 80% of lower limb ulcers have a venous origin
• other common causes are arterial insufficiency and diabetic-related neuropathy
• rarer causes are:
  
  • trauma
  • infection
  • vasculitis
  • malignancy (usually squamous cell carcinoma)

Question 3

What type of ulcer may also occur in someone who is less mobile?

Answer 3

pressure ulcers

• these are caused by prolonged or excessive pressure over a bony prominence
• this leads to skin breakdown and eventual necrosis

Question 4

How is the appearance of venous and arterial ulcers different?

Answer 4

Venous ulcers:

• shallow ulcers with a granulated base
• there are often other clinical features of venous insufficiency present

Arterial ulcers:

• tend to be found at distal sites with other evidence of arterial insufficiency
• they are often “punched-out” lesions with well-defined borders

Question 5

What are neuropathic ulcers and where do they typically occur?

Answer 5

• painless ulcers over areas of abnormal pressure, often secondary to joint deformity in diabetics

Question 6

What directly causes a venous ulcer?

How can they be identified and where are they most commonly found?

Answer 6

• caused by venous insufficiency
• they are shallow with irregular borders and a granulating base
• they are typically located over the medial malleolus

Question 7

How do venous ulcers typically present to the GP?

Answer 7

• they are prone to infection so often present with associated cellulitis

Question 8

What is thought to be the pathophysiology behind why venous ulcers occur?

Answer 8

• valvular incompetence or venous outflow obstruction leads to impaired venous return
• this leads to venous hypertension
• this causes trapping of WBCs in capillaries and the formation of a fibrin cuff around the vessel
• this hinders oxygen transportation into the tissue
• WBCs become activated and release inflammatory mediators, leading to resultant tissue injury, poor healing and necrosis

Question 9

What are the risk factors for developing venous ulcers?

Answer 9

• increasing age
• pre-existing venous incompetence or history of VTE
  
  • this includes varicose veins
• pregnancy
• obesity or physical inactivity
• severe leg injury or trauma

Question 10

Are venous ulcers painful?

What associated symptoms of chronic venous disease may be present alongside the ulcer?

Answer 10

• they can be painful and are worse at the end of the day
• they are often found in the gaiter region of the legs
• associated symptoms of chronic venous disease are aching, itching or a burning sensation
  
  • these are often present before venous leg ulcers appear

Question 11

When examining a venous ulcer, what features associated with venous insufficiency might be present?

Answer 11

• varicose eczema
• thrombophlebitis (blood clot in one or more veins)
• haemosiderin skin staining
• lipodermatosclerosis
• atrophie blanche

Question 12

What is haemosiderin deposition and why does it occur?

Answer 12

• haemosiderin deposition occurs due to venous insufficiency and blood pooling in the veins
• haemosiderin staining occurs when red blood cells leak through the veins
• iron pigments leak into the skin, which shows up as brown patches or stains

Question 13

What is lipodermatosclerosis?

What does it look like?

Answer 13

• a chronic inflammatory condition characterised by subcutaneous fibrosis and hardening of the skin on the lower legs
• it is a panniculitis (inflammation of the layer of fat under the epidermis)

Question 14

What is atrophie blanche?

Answer 14

• it describes the result of healed ulcers
• it presents as a white, atrophic stellate scars with peripheral telangiectasia
• it occurs after skin injury when the blood supply is poor and healing is delayed

Question 15

How are venous ulcers diagnosed?

Where does venous incompetence most commonly occur?

Answer 15

• they are diagnosed clinically
• underlying venous insufficiency is confirmed with Duplex Ultrasound
• venous incompetence occurs at the sapheno-femoral or sapheno-popliteal junctions

Question 16

Why is ankle-brachial pressure index (ABPI) assessed when there is a venous ulcer?

Answer 16

• ABPI is required to assess whether there is an arterial component to the ulcers and to determine whether compression therapy will be suitable

Question 17

What other test might be considered if a venous ulcer is erythematous or with purulent exudate?

Answer 17

• this means that infection should be suspected
• swab cultures should be taken
• antibiotics should be given

Question 18

What should be considered in younger patients presenting with venous ulcers?

Answer 18

• consider a thrombophilia and vasculitic screening in young patients
• especially if there is a suspicion or family history of prothrombotic and autoimmune diseases

Question 19

What is involved in the conservative management for venous ulcers?

Answer 19

• leg elevation and increased exercise
• this promotes the calf muscle pump action, which aids venous return
• lifestyle changes such as improved diet and weight reduction should also be encouraged

Question 20

When are antibiotics prescribed for venous ulcers?

Answer 20

• ONLY when there is clinical evidence of a wound infection
• most wounds are colonised, so swab results should only be acted upon if there is evidence of infection

Question 21

What is the main method of management for venous ulcers?

Answer 21

multicomponent compression bandaging

• these should be changed once or twice a week for 6 months
• this improves healing time

Question 22

What measurement must be taken before applying compression bandaging?

What can be used alongside this to promote skin health?

Answer 22

• ABPI must be at least 0.6 or more before any bandaging is applied
• appropriate dressings and emollients are crucial to maintain the health of the surrounding skin

Question 23

What causes an arterial ulcer?

Answer 23

• it is caused by reduction in arterial blood flow
• this leads to decreased perfusion of the tissues and subsequent poor healing

Question 24

What do arterial ulcers typically look like?

Where do they most commonly occur?

Answer 24

• they form small deep lesions with well-defined borders and a necrotic base
• they most commonly occur distally at sites of trauma and in pressure areas (e.g. heel)

Question 25

What are the risk factors for developing arterial ulcers?

Answer 25

the main risk factors are those of peripheral arterial disease

• smoking
• diabetes
• hypertension
• hyperlipidaemia
• increasing age
• positive family history
• obesity and physical inactivity

Question 26

What other symptoms are usually present in the history of someone presenting with an arterial ulcer?

Answer 26

• history of intermittent claudication
  
  • this is pain on walking
• history of critical limb ischaemia
  
  • ​this is pain at night

Question 27

How long does it take for an arterial ulcer to develop?

What are other associated signs that might be present?

Answer 27

• they are painful ulcers that develop over a long period of time
• there is little to no healing, meaning there is no or little granulation tissue
• associated signs include:
  
  • cold limbs
  • thickened nails
  • necrotic toes
  • hair loss

Question 28

In someone with an arterial ulcer, what will the limb be like on examination?

What signs need to be assessed for?

Answer 28

• the limbs will be cold and have reduced or absent pulses
• in pure arterial ulcers, sensation is maintained (unlike neuropathic ulcers)
• assess for signs of venous insufficiency as some patients have mixed pathology

Question 29

Why is an ABPI performed on a suspected arterial ulcer and what readings would be pathological?

Answer 29

• ABPI can quantify the extent of any peripheral arterial disease
• > 0.9 is normal
• 0.8 - 0.9 is mild
• 0.5 - 0.8 is moderate
• < 0.5 is severe

Question 30

What is involved in the conservative management of arterial ulcers?

Answer 30

• patients should be advised about lifestyle changes, such as:
  
  • smoking cessation
  • weight loss
  • increased exercise

Question 31

What is involved in the medical management of arterial ulcers?

Answer 31

• suitable pharmacological cardiovascular risk factor modification should be prescribed
• this includes statin therapy
• with an antiplatelet agent, such as aspirin or clopidogrel
• and optimisation of blood pressure and glucose

Question 32

When might surgical management of arterial ulcers be considered?

What does this involve?

Answer 32

• this involves angioplasty (with or without stenting) or bypass grafting for more extensive disease
• any non-healing ulcers, despite a good blood supply, may also be offered skin reconstruction with grafts

Question 33

What is a neuropathic ulcer?

Why do they tend to occur and what concurrent disease can contribute to their formation?

Answer 33

• it is an ulcer that occurs as a result of peripheral neuropathy
• there is a loss of protective sensation, leading to repetitive stress and unnoticed injuries forming
• this results in painless ulcers forming on the pressure points of the limb
• concurrent vascular disease contributes to their formation and reduces healing potential

Question 34

What are the risk factors for neuropathic ulcers?

Answer 34

• they can develop with any condition with peripheral neuropathy
• the most common is diabetes mellitus and vitamin B12 deficiency
• ulcer risk is increased further by any foot deformity or concurrent peripheral vascular disease

Question 35

What are the key factors to pick up in the history of someone presenting with neuropathic ulcers?

Answer 35

• history of peripheral neuropathy (although patient might be unaware)
• or symptoms of peripheral vascular disease

Question 36

What are other clinical manifestations of neuropathic ulcers?

Answer 36

• burning / tingling in the legs (painful neuropathy)
• single nerve involvement (mononeuritis multiplex)
  
  • usually involves CN III or the median nerve
• painful wasting of the proximal quadriceps (amotrophic neuropathy)

Question 37

What do neuropathic ulcers look like on examination?

Where do they commonly occur?

Answer 37

• they are variable in size and depth
• they have a “punched out” appearance
• they occur most commonly on sites of pressure on the feet, such as the metatarsal heads or heels

Question 38

What does the limb typically look like on examination in a neuropathic ulcer?

What other symptom may be present?

Answer 38

• there may be peripheral neuropathy, which is typically in a “glove and stocking” distribution
• the feet should be warm with good pulses unless there is an element of concurrent arterial disease

Question 39

What initial investigations are carried out if a neuropathic ulcer is suspected?

Answer 39

• blood glucose levels should be checked - either random glucose or HbA1c
• serum B12 levels should be checked
• concurrent arterial disease should be assessed with an ABPI +/- duplex

Question 40

What additional investigations are conducted in neuropathic ulcers if infection is suspected?

Answer 40

• signs of infection require a microbiology swab
• signs of deep infection (e.g. visible bone or ulcers extending into joints) may warrant an X-ray to assess for osteomyelitis

Question 41

How is the extent of peripheral neuropathy assessed?

Answer 41

• using the 10g monofilament or Ipswich touch test
• along with testing vibration sensation with a 128Hz tuning fork

Question 42

What steps are involved in the management of neuropathic ulcers?

Answer 42

• diabetic control should be optimised, targeting HbA1c < 7%
• improved diet and increased exercise (within limits) is encouraged
• cardiovascular risk factors need to be managed
• regular chiropody to maintain good foot hygiene and appropriate non-weight bearing footwear