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INVITED COMMENT Chronic leg ulcers: The impact of venous disease

David Bergqvist, MD, PhD, Christina , RN, PhD, and Olle Nelzén, MD, PhD, ,

Chronic leg ulceration of various causes has been PREVALENCE OF LEG ULCERS a health care problem throughout history. The prob- Differences in leg prevalence between vari- lematic consequences of the disease and the difficul- ous studies may have several causes, such as the use ties in the promotion of conditions once cre- of overall or point prevalence, the inclusion or exclu- ated the need for a special saint for chronic leg ulcers, sion of foot ulcers, the age and sex distribution in St Peregrinus. At one of the oldest hospitals in the patient series, and the methodology of identify- Sweden, patients with leg ulcers comprised a large ing patients. With a combination of questionnaires proportion of all in-hospital patients during the years to the health care system (eg, wards, outpatient clin- 1767 to 1771.1 Both internal (laxatives) and external ics, nurses) and questionnaires to randomly selected (turpentine, ) treatment options were used, individuals within the population and a thorough and, after a couple of months, at least some of the investigation of the random samples of responders, it ulcers healed. Bandaging therapy was mentioned would seem as if an optimal estimate is obtained. We already in the Old Testament of the Bible (Isaiah have been especially interested in an investigation of 1:6). In 1916, John Homans2 classified ulcers as vari- the ulcer situation in three Swedish regions—the city cose and postphlebitic: the first was curable with vari- of Malmö (urban population), the county of cose surgery, and the latter was practically not Skaraborg (rural population), and the county of curable with surgical methods. To correctly treat Uppsala (mixed population). The populations in the chronic leg ulcers, it is a prerequisite to have a three regions are fairly similar (250,000 to 300,000 detailed knowledge of the cause and the distribution inhabitants). within the population. The aim of this report is to One obvious problem is the large number of review the epidemiologic situation on the basis of patients, especially younger male patients, who are data primarily from Sweden, with special emphasis on not known to the health care system.6,7 These the impact of venous disease. A chronic leg ulcer is patients take care of the ulcers themselves, and defined as any below the knee, the foot among them, there are, without doubt, patients with included, that does not heal within a 6-week period. curable diseases, such as superficial venous insuffi- One important problem is the multifactorial etiology ciency. The overall or lifetime prevalence is roughly of leg ulcers, and there are many contributing factors three times higher than the point prevalence, and (eg, venous , , diabetes, there is a clear increase with age (Table I). The life tumors, arthrosis, collagenosis, varicose ). time prevalence includes all the people who have Another problem is that approximately 30% to 40% ever had a leg ulcer, whereas the point prevalence of ulcers may have more than one cause, which will measures the people with open ulcers during a lim- influence how to treat the patient and the ulcer.3-5 ited period of time. The point prevalence gives the actual size of the problem and thereby an estimate of From the Department of Surgery and Centre of Caring Sciences, Hospital. the workload of the health care professionals at any Reprint requests: Dr David Bergqvist, Professor of Vascular point of time. With a combination of the results Surgery, Department of Surgery, University Hospital, S-751 85 from three comparable studies in Skaraborg county Uppsala, Sweden. and the city of Malmö, 2.4% of the adult population J Vasc Surg 1999;29:752-5. older than 15 years had ever had leg ulcers and 5.6% Copyright © 1999 by the Society for Vascular Surgery and International Society for Cardiovascular Surgery, North of people 65 years or older had open or healed lower 6-10 American Chapter. limb ulceration. The yearly incidence rate can be 0741-5214/99/$8.00 + 0 24/9/96438 estimated to be between 0.03% and 0.06%.5

752 JOURNAL OF VASCULAR SURGERY Volume 29, Number 4 Bergqvist, Lindholm, and Nelzén 753

Table I. Overall prevalence of leg ulcer in Table II. Etiologic classification of chronic leg Skaraborg county (%) ulcers with examples from the Skaraborg study3 (%)

Known to No. of ulcers No. of isolated health care system Self care included above the foot foot ulcers All causes Venous All causes Venous Etiologic classification (n = 353) (n = 110)

Total population 0.90 0.49 1.90 1.03 Venous 52 2 >15 years old 1.20 0.65 2.40 1.30 Mixed venous/arterial* 18 1 >64 years old 4.20 2.27 5.60 3.02 Mixed arterial/venous† 4 5 Arterial 4 19 Arterial and diabetes 2 34 Diabetes 1 14 Traumatic 2 1 CAUSES AND CHARACTERISTICS OF LEG Pressure <1 13 ULCERS Multifactorial (arterial, venous, 3 3 diabetes) There are many causes of leg ulcers. The prob- Multifactorial (others) 8 4 lem is even greater in that one patient may have sev- Other single causes 6 4 eral causes and that this may vary with time. So, a The classification was made by one surgeon who combined clini- patient with a long-standing, pure may cal and physiologic findings. have arterial insufficiency develop with increasing *Venous cause dominating. †Arterial cause dominating. age, which adds to the problem and makes treat- ment more difficult. One etiological classification is exemplified in Table II, where there is a combina- tion of clinical and physiologic findings and the clin- patients still have ulcers develop with time.16,17 If ician decides on the most probable cause. A random patients with current ulcers are analyzed retrospec- sample of the patients in the Skaraborg prevalence tively, approximately 25% have a history of deep vein study was investigated by a clinician. In Table III, thrombosis.3 Of 287 patients without popliteal the main causes of chronic leg ulcers in the three reflux, 29 (10%) had a history of deep vein throm- Swedish regions previously mentioned are summa- bosis; of 176 with popliteal reflux, 86 (49%) had rized. One important methodologic difference such a history; and, moreover, 65 (37%) had a his- should, however, be noticed. In the Skaraborg study, tory of major surgery or fracture, in which we know the diagnosis was established on the basis of one that the risk of is high. Among physician’s combined clinical and physiologic inves- patients with venous ulcers, 37% had a history of tigation. In the two other counties, the diagnosis previous thrombosis.11 A positive history of throm- was made on the basis of a questionnaire, mostly the bosis was significantly more common in patients clinical investigation by a large number of nurses. with deep vein insufficiency (54%) as compared with Venous and nonvenous ulcers have a difference in patients with ulcers from isolated superficial vein distribution, with nonvenous being more peripheral- insufficiency (14%). ly located. So, only 9% of the foot ulcers are venous There are several important differences between and 55% are nonvenous. venous and nonvenous ulcers, some of which are The distribution of venous insufficiency in 463 shown in Table V. Because the median age of the legs with current ulcers3 can be seen in Table IV. patients is high, there is also a high frequency of This classification was made with a combination of associated diseases. Those patients with arterial clinical and hand-held Doppler scan examinations ulcers have a higher frequency of diabetes, myocar- (before the era of duplex scanning). Of those cases dial infarction, and intermittent than do with venous insufficiency, 47% were purely superfi- those patients with venous ulcers, who, on the other cial and 53% were deep, in 42% with a superficial hand, have more deep vein thrombosis and varicose component as well. This is important because ulcers veins.5 The various ulcer groups do not differ in that are caused by superficial insufficiency are poten- smoking habits. tially curable with surgical treatment.3,11,12 The influence of previous deep is dif- SOCIOECONOMIC FACTORS ficult to evaluate, but the frequency is high in older To analyze the socioeconomic factors, 78 studies without treatment.13-15 In a patients with leg ulcers were compared with 271 recent series with adequate treatment, the frequency control patients without ulcers, all of whom were has decreased, but between 5% and 10% of the identified in a population survey in Malmö and JOURNAL OF VASCULAR SURGERY 754 Bergqvist, Lindholm, and Nelzén April 1999

Table III. Causes of chronic leg ulcers (%) Table IV. Distribution of venous insufficiency in 463 legs with current ulcers (%) Skaraborg county Uppsala county Malmö city (n = 463) (n = 406) (n = 257) Ulcer above the foot Foot ulcer

Venous 40 29 34 Femoral vein 27 4 Mixed 18 14 11 Popliteal vein 45 15 Arterial/diabetes 21 8 21 Long saphenous vein 31 9 Traumatic 2 18 2 Short saphenous vein 44 16 Others 19 31 32 Calf perforators 56 13

All ulcers, including foot ulcers, are included. As understood from summarizing the columns, there are various types of combinations.

Table V. Comparison between venous and nonvenous chronic leg ulcers

Venous Nonvenous P value

Median patient age (years; range) 77 (39 to 97) 77 (13 to 91) Diabetes (%) 8 47 <.001 History of thrombosis (%) 37 11 <.0001 Median age at first ulcer (years; range) 59 (14 to 92) 73 (12 to 94) <.001 Median duration of ulcer history (years) 13.4 2.5 <.001 Recurrent ulcer (%) 72 45 <.001

Skaraborg.5 Except for a significantly lower income ulcer treatment in Sweden has been calculated to in the ulcer group, there was a surprising lack of dif- 250 Swedish Kroner per day, which would be a year- ferences in socioeconomic factors. So, 74% of the ly cost in Sweden of 2 billion SEK.5 This figure patients with ulcers earned less than $12,500 per excludes the people in selfcare, who induce a sub- year as compared with 50% of the patients without stantial indirect cost for the society. Another way to ulcers. One important factor is the high frequency of express the cost is that, in a county of Uppsala’s size immobile patients with leg ulcers. In the Skaraborg (290,000 inhabitants), 57 nurses were occupied full study, only 40% walked without some sort of sup- time with leg changes, which means a cost port and 18% used a wheelchair regularly. for salary of approximately 15 million SEK per year.

PRESENT TREATMENT PROGNOSIS Leg ulcer treatment by tradition has been con- In the Skaraborg study, at a mean follow-up peri- sidered of secondary interest by most health care od of 54 months, 54% of the venous ulcers were workers. This is reflected in the large number of var- healed, 43% were open, and 3% of the legs were ious local treatments found in a recent survey in amputated.20 In Uppsala, 40% of the leg ulcers were Uppsala county in which 113 types of local wound healed within 3 months. The recurrence of healed treatments were identified. Dressing changes were venous ulcers is common. In patients with current made by district nurses in 52% of the cases, by other venous ulcers, as many as 33% have their fourth health care workers in 40%, by relatives in 2%, and by episode of ulceration and 60% to 70% are already the patients themselves in 6%. In 6% of the patients recurrent.11,21 The long-term outcome for patients with venous ulcers, the dressings were changed 2 to with ulcers caused by deep venous insufficiency 3 times daily; in 36%, once daily; in 37%, 2 to 3 appears to be worse than for patients with ulcers times a week; and in 21%, once a week.11 In the caused by superficial venous insufficiency or perfo- Skaraborg study, 74% of the patients with venous rating vein incompetence alone.11,20 To prevent ulcers used daily compression as compared with 22% recurrence, adequate compression is extremely of the patients with nonvenous ulcers.11 Pain is a important.19,22,23 Leg ulcer clinics with dedicated major problem in both venous and nonvenous leg health care personnel, a multidisciplinary approach, ulcerations.18,19 In an interview study in the and systematic care programs can at least improve Uppsala county, 89% of all the patients with leg the short-term healing of ulcers in the communi- ulcers reported pain. The annual cost of venous leg ty.24,25 Treatment in leg ulcer clinics also seems to JOURNAL OF VASCULAR SURGERY Volume 29, Number 4 Bergqvist, Lindholm, and Nelzén 755 give a better quality of life.26 Patients with leg ulcers, 9. Nelzén O, Bergqvist D, Hallböök T, Lindhagen A. Chronic as a group, have a significantly decreased 5-year sur- leg ulcers: an underestimatd problem in primary health care among elderly patients. J Epidemiol Community Health vival rate as compared with a matched control pop- 1991;45:184-7. 20 ulation (67%). However, with the analysis of 10. Lindholm C, Bjellerup M, Christensen OB, Zederfeldt B. patients with ulcers on the basis of cause, patients Leg and foot ulcers. A demographic survey of leg and foot with venous ulcer have a normal expected survival ulcer patients in a defined population. Acta Derm Venereol rate, whereas those with arterial ulcers and ulcers of 1992;7:227-30. 11. Nelzén O, Bergqvist D, Lindhagen A. Venous and non- other causes have a significantly decreased survival venous leg ulcers; clinical history and appearance in a popu- rate. Thus, patients with venous leg ulcers are likely lation study. Br J Surg 1994;81:182-7. to live with their ulcers for a long period of their life 12. Scriven JM, Harthsorne T, Bell PRF, Naylor AR, London unless a curative treatment is offered. NJM. Single-visit venous ulcer assessment clinic: the first year. Br J Surg 1997;84:334-46. CONCLUDING REMARKS 13. Bauer G. A roentgenological and clinical study of the sequels of thrombosis. Acta Chir Scand 1942;86(suppl 74):1-112. The problem of leg ulcers seems to remain. The 14. Zilliacus H. On specific treatment of thrombosis and pul- enormous costs to the society of leg ulcers have been monary with , with particular refer- realized. An often complex etiology makes diagnosis ence to the post-thrombotic sequelae. The results of five and proper classification of ulcers essential to pro- years treatment of thrombosis and at a series of Swedish hospitals during the years 1940-1945 vide optimal treatment. There is enough basic infor- [suppl]. Acta Med Scand 1946;112:1-196. mation to organize effective treatment pathways. A 15. Gjöres JE. The incidence of venous thrombosis and its seque- multidisciplinary approach seems to be a prerequi- lae in certain districts of Sweden. Acta Chir Scand 1956; site for improvements in leg ulcer care. A substantial 106(suppl 206);1-88. proportion of so-called “chronic” leg ulcers are not 16. Lindhagen A, Bergqvist D, Hallböök T, Efsing HO. Venous function five to eight years after clinically suspected deep chronic provided that adequate treatment is given. venous thrombosis. Acta Medica Scandinavica 1985;217: Today there should be knowledge enough to sub- 389-95. stantially decrease the size of the leg ulcer problem. 17. Bergqvist D, Jendteg S, Johansen L, Persson U, Ödegaard K. Cost of long-term complications of deep venous thrombosis We thank the Swedish Medical Research Council of the lower extremities: an analysis of a defined patient pop- 00759. ulation in Sweden. Ann Intern Med 1997;126:454-7. 18. Hofman D, Lindholm C, Arnold F, Bjellerup M, Cherry G. REFERENCES Pain in venous leg ulcers. J Wound Care 1997;5:222-4. 19. Lindholm C, Marklund B. Venous leg ulcers: history, epi- 1. Hallböök T. Sjukvården 1767-1771 vid Mariestads Lazaret. demiology, pathology, etiology, treatment, and care. J Surg Sveriges äldsta länslasarett. Sydsvenska Medicinhistoriska Pathol 1997,2:209-17. Sällskapets Årsskrift 1997;34(Suppl 23):1-64. 20. Nelzén O, Bergqvist D, Lindhagen A. Long-term prognosis 2. Homans J. The operative treatment of and for patients with chronic leg ulcers: a prospective cohort ulcers, based upon a classification of these lesions. Surg study. Eur J Vasc Endovasc Surg 1997;13:500-8. 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Uppsala; Acta Universitatis Phlebology 1992;7:23-6. Upsaliensis; 1997. p. 1-88. 24. Moffat CJ, Franks PJ, Oldroyd M, Bosanquet N, Brown P, 6. Nelzén O, Bergqvist D, Lindhagen A. The prevalence of chron- Greenhalgh RM, et al. Community clinics for leg ulcers and ic lower-limb ulceration has been underestimated: results of a impact on healing. BMJ 1992;305:1389-92. validated population questionnaire. Br J Surg 1996;83:255-8. 25. Åkesson H, Bjellerup M. Leg ulcers: report on a multidisci- 7. Nelzén O, Bergqvist D, Fransson C, Lindhagen A. plinary approach. Acta Derm Venereol 1995;75:133-5. Prevalence and aetiology of leg ulcers in a defined population 26. Franks PJ, Moffat CJ, Connolly M, Bosanquet N, Oldroyd of industrial workers. Phlebology 1996;11:50-4. MI, Greenhalgh RM, et al. Community leg ulcer clinics: 8. Nelzén O. Bergqvist D. Chronic venous insufficiency and leg effect on quality of life. Phlebology 1994;9:83-6. ulcers: how big is the problem? In: Goldstone J, editor. 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