Venous ulcers are wounds or open sores on the lower extremities, which are very slow to heal and often reoccur. They affect over 500,000 people in the United States and account for 80-90% of all leg ulcers. They are associated with venous valvular insufficiency or may be a complication of a post-thrombotic syndrome (blood clots) but the pathway to venous ulcers is venous hypertension and the underlying associated inflammatory process. The patient may suffer from pain, infection and disfigurement. Venous ulcers are more common in people who have a history of leg swelling, pain, varicose veins or a history of previous blood clots in the deep venous system. The ulcers are associated with considerable economic, psychological and social impact. Treatment is available which dramatically improves the ulcer but requires patients seeking physicians who specialize in the field of phlebology.
Veins located in the lower extremities are blood vessels, which return blood to the heart. When the valves inside the veins become damaged and fail to work properly or if there is an obstruction to blood flow secondary to a blood clot in the vein, then blood pools and backs up in the lower extremities. This increased pressure in the veins causes fluid to leak into the surrounding tissues. Swelling develops followed by an intense inflammatory response in the tissues or vein walls. Movement of oxygen and nutrients from capillaries into the tissue is reduced and leads to tissue breakdown and ulcer formation.
Venous ulcers are most commonly located around the inside anklebone (medial malleolus), but may be located just above the outside anklebone (lateral malleolus). The first sign of an impending ulcer is the appearance of a dark purple or red skin over the affected area. Often the skin is dry and has the appearance of a rash or eczema. Venous ulcers may rapidly develop once these skin changes are present.
Symptoms of lower extremity venous ulcers include swelling, pain, skin color changes, dry skin or rashes. The borders of the ulcer are usually irregular and they often weep a clear fluid while being covered in a yellowish film. Venous ulcers can become infected and with such drain a malodorous pus. These ulcers are more tender and inflamed in appearance.
Venous ulcers can be diagnosed with a history and physical exam along with a duplex Doppler exam. On occasion, an MRV (magnetic resonance venogram) may be required. A vein specialist can easily differentiate venous ulcers from other causes of ulcers including arterial (ischemic ulcers) and neurotrophic (diabetic) ulcers.
Treatment goals of venous ulcers include relief of pain and healing of the ulcer as well as preventing recurrence of the ulcers. The treatment options will be individualized by the vein doctor based on the location, size and duration of the venous ulcer. Venous ulcers are treated with compression dressings and compression stockings, which minimize the swelling. The type of compression dressings will be determined by your vein doctor
Compression therapy to reduce venous hypertension can be either inelastic or elastic bandages. The inelastic bandage, such as The Unna Boot, applies increase pressure with activity but must be replied more frequently.
Elastic Bandages are easier to use and patients tend to be more compliant with this type of compression therapy.
Patients with a history of venous ulcers may need to wear the compression stocking (30-40mmhg) their entire life to help prevent recurring ulcer formations.
Topical wound care treatment may be necessary along with antibiotics if they appear infected. Elevation of the leg will also help to reduce the swelling and venous hypertension. Venous ulcers may take months to heal and may chronically reoccur.
The second approach to healing venous ulcers is by closure of the incompetent venous system, which causes the underlying venous hypertension. This can be achieved by methods such as endo-thermal ablation of the great or small venous system or perforator vein when found incompetent with the use of radio frequency or laser systems.
Sclerotherapy, ligation and subfascial endoscopic perforator surgery can also be used to treat incompetent perforators, which cause venous ulcers.
These surgical techniques offer promising results with fewer recurrences of the venous ulcer over compression stockings as a stand-alone treatment. For the best results, the patient is to seek medical advice from doctors who specialize in the treatment of vein disease.