Venous ulcer
Arterial ulcer
Ulcer of mixed aetiology
DEFINITION
Leg ulcers may be defined as an open lesion on the lower limb due to full thickness skin loss resulting in chronic wound progression. The ulcer may be surrounded by hard or discoloured tissue with reduced circulation, the state of the skin surrounding the ulcer is extremely important to the outcome, the healthier the surrounding area the greater the success of healing.
Ulcers tend not to heal spontaneously and often reoccur. This can be very incapacitating, especially if complications ensue. Treating leg ulcers has a high societal cost both in terms of healthcare expenditure and psychological burden upon the patient.
PATHOPHYSIOLOGY
Ulcers usually originate (95% of cases) from an arterial or venous circulatory disorder. The proportion of ulcers with a mixed arterial-venous origin has increased during the past few decades, as a result of an ageing population with concomitant arterial problems. This aetiology further complicates the healing.
DIFFERENTIAL DIAGNOSIS
To determine the predominant origin of a mixed ulcer and/or make sure that there is no arterial disease present, the ankle-brachial pressure index (ABPI) should always be measured.
Ankle-brachial pressure index (ABPI)
Some conditions cause wounds that are similar in appearance to leg ulcers due to vascular complications. It is therefore very important that these different conditions are not confused since the appropriate treatment for one disease may be contraindicated for another one.
Other vascular causes are represented by hypertension (Martorell), diabetes, haematological and clotting disorders.
Rarer causes include vasculitis, pyoderma gangrenosum, infectious diseases, malignancies (carcinomas), calciphylaxis (diabetes) and drug-induced ulcers (hydroxyurea).
It is also important to observe carefully chronic ulcers caused by malignant diseases, these include:
- Basal cell carcinoma
- Squamous cell carcinoma
- very rare skin metastases observed in systemic cancers.
COMPLICATIONS OF ULCERS
Complications resulting from leg ulcers include loss of mobility and the risk of infection. Immobility can make the ulcer worse, due to increased venous blood pressure (venous hypertension) and also increase the patient’s dependence and sense of isolation.
Occasionally long term infection can lead to conditions such as cellulitis or septicaemia. Unusually, if ulcers are present for many years a malignant tumour may arise (squamous cell carcinoma) with a poor prognosis.
For some patients the psychological impact of leg ulcers leads to anxiety and depression the mental health of the patient should be carefully monitored and the appropriate support provided if necessary.
TREATMENT OF ULCERS
If the underlying medical cause of the ulcer is known then it is essential to treat it.
VENOUS OR MIXED AETIOLOGY ULCER
- Hypertension will respond to medication and weight reduction may also be implemented.
- If exercise is possible a minimal regimen of moderate exercise will help improve the blood flow in the legs.
- If the patient has diabetes then their blood sugar levels should be closely monitored and their treatment reassessed.
- In the presence of venous incompetence, varicose vein surgery is effective in patients who can still receive this treatment
ARTERIAL ULCERS
In ulcers of arterial origin, revascularisation of the lower limb is the first treatment to propose: balloon angioplasty or stenting that relieves obstruction of the artery or by-pass surgery are procedures that should be considered.
Pain is an overriding problem in patients with arterial ulcers and this should always be addressed.