venous ulcer Flashcards
definition of venous ulcer
a break in the epithelial surface that has not healed in 2 weeks - caused by increased venous pressure
superficial venous insufficiency
aetiology of venous ulcers
caused by sustained venous hypertension - from chronic venous insufficiency due to venous valve incompetence or an impaired calf muscle pump
in normal venous system in exercise:
- calf muscle pump = reduction of venous pressure
- when calf muscle relaxes: valves in perforating veins prevent reflux of blood and pressure remains low
if reflux of blood due to valve damage or calf muscle pump impairment = venous pressure remains high = enlarged veins, oedema, venous skin changed (hyperpigmentation, venous eczema, lipodermatosclerosis and atrophie blanche)
as condition of skin and subcut tissue worsens = increasingly vulnerable to ulcer
RF of venous ulcer
age
obesity
immobility
limited range of ankle function
previous ulcer
personal or FH of varicose veins
personal history of DVT
female
multiple pregnancies
arteriovenous fistula
history of leg fracture or trauma
sedentary lifestyle
prolonged standing
epidemiology of venous ulcer
venous disease accounts for 70% leg ulcers
The estimated prevalence in the UK is between 0.1–0.3%
leg ulcers affect approx 2% people in developed countries
The prevalence is predicted to increase dramatically because people are living longer, often with multiple comorbidities
The estimated lifetime risk of developing a venous leg ulcer is 1%
Venous leg ulcers occur in people from all socioeconomic groups, but ulcers take longer to heal and recurrence rates are higher in people from lower socioeconomic groups
sx of venous ulcer
most commonly just above ankle (gaiter region)
shallow ulcer with irregular borders
only mild pain
pruritic
heaviness of leg
sx of venous insufficiency
generalized or localized pain, lower extremity discomfort/cramping, and limb swelling
- worsened by heat
- worse while standing, relieved by walking and raising legs
pruritus (itch), tingling, numbness
skin findings in venous ulcer/venous insufficiency
oedema - starts in ankle and may involve calf
telangiectasia
yellow-brown or red-brown skin pigmementation of medial ankle, later of foot and possibly lower leg
- RBC breakdown leads to hemosiderin release → accumulation in the dermis → skin pigmentation
- May lead to stasis dermatitis; a scaly, pruritic rash
paraplantar varicose veins
lipodermatosclerosis - localised chronic inflammatiuon and fibrosis of skin and subcut tissues of the lower leg
- painful, indurated and hardened skin
- atrophie blanche - white, coin to palm sized atrophic plaques due to absent capillaries in the fibrotic tissue
signs of venous ulcer
note features: site, number, surface area, depth, edge, base, discharge, lymphadenopathy, sensation and healing
site - typically in gaiter region
wound edge - gently sloping, irregular edges. (‘Punched out’, rolled, or everted edges should raise the suspicion of an alternative diagnosis.)
Appearance of the wound bed — look for granulation tissue (an indicator of wound healing), and slough (dead tissue, usually cream or yellow in colour) or necrotic tissue, which may need to be removed to allow healing.
amount of exudate - excessive might be due to wound infection or gross oedema in wound area - amount determines dressing
signs of infection - cellulitis (pain, warm, swelling and erythema), fever, increased pain, rapid extension of area of ulceration, malodour and increased exudate
varicose veins
signs of venous insufficiency
pitting oedema (rule out non-venous causes eg HF and CKD)
skin changes
- hyperpigmentation,
- venous eczema (itchy, red, scaly, and/or flaky skin which may have blisters and crusts on the surface),
- lipodermatosclerosis (painful, hardened, tight skin),
- atrophie blanche (star-shaped, ivory-white, depressed, atrophic scars with surrounding pigmentation)
signs of PAD
hair loss
pallor
coldness
dusky appearance on lower leg
cap refill >4sec
peripheral pulses
abdo - aneurysm
Ix for venous ulcers
doppler assessment of both legs to determine ankle brachial pressure index (ABPI) - to exclude arterial insufficiency
FBC - anaemia may delay healing, high WCCC and platelet could = infection
ESR or CRP - inflamm and infec
Urea and creatinine - high urea = dehydration = impaired healing
albumin- low = protein loss and malnutrition = delayed healing
HbA1c - dm
bacterial swabs only taken when clinical evidence of infection
skin and ulcer biopsy maybe (should be performed in any nonischemic wound that fails to improve after 3 months of treatment) - assess for vasculitis (will need immunohistopathology) or malignant change
interpreting ABPI
index of vessel competency by measuring the ratio of systolic blood pressure at the ankle to that in the arm
1 = normal
<0.5 - severe arterial disease - compression treatment CI
- 5-0.8 - arterial/mixed arterial and venous - compression generally avoided, reduced compressuon used under specialist advice w/ strict supervision
- 8-1.3 - no sig arterial disease, compression safe in most
>1.3 - arterial calcification eg dm, RA, systemic vasculitis, atherosclerotic siease and advanced chronic renal failure = ABPI misleadingly high
Compression therapy should be used with caution in people with diabetes, who may have unreliable ABPIs due to arterial calcification as well as an underlying sensory neuropathy.
ABPI values should always be interpreted in the context of signs and symptoms. eg if normal but have symptoms of peripheral arterial disease consider referral
Mx of venous ulcers
assess need for immediate referral:
- diagnostic uncertainty
- rapidly deteriorating or atypical location and/or appearance
- suspected alternative cause of ulceration
- poor ankle mobility, reduced joint func or history of falls
- suspected iliac vein stensosis - may need CT venography and IV US
compression therapy immediately if appropriate - clean and dressed 1st
after compression refer if:
- suspected contact dermatitis
- osteomyelitis
- sepsis
- necrotising fasciitis
- uncontrolled pain
pentoxifylline potentially - adjunct to compression, may be useful w/o compression
manage oedema, venous eczema, pain and infection
after healed - compression stockings to prevent recurrence of ulceration
woudn treatment - debridement, skin care, dressing
skin graft in large/refractory ulcers
treat underlying disease
lifestyle for venous ulcers
compliance with compression therapy
keep mobile with regular walking - exercise calf muscle func
elevate legs when immobile
well fitting footwear
emollient frequently, avoid products that may contain any identified sensitizing agents (such as lanolin and preservatives).
Examine their legs regularly for broken skin, blisters, swelling, or redness.
lose weight if relevant
balanced diet
watch alcohol
stop smoking
complications of venous ulcer
chronic pain
impaired mobility
infection - inc osteomyelitis and septicaemia
allergic contact dermatitis - caused by allergens in creams and dressings, such as preservatives, emulsifiers, latex, resins, lanolin, and topical steroids, antibiotics, and antiseptics
Malignant transformation in the ulcer bed (Marjolin’s ulcer).
Sinus formation and fistula (uncommon).
Negative impacts on quality of life and daily functioning — time off work, psychological distress, loss of independence, and social isolation - common.
vein haemorrhage
superficial thrombophlebitis
DVT
