Diagnosis and Treatment of Venous Ulcers LAUREN COLLINS, MD, and SAMINA SERAJ, MD, Thomas Jefferson University Hospital, Philadelphia, Pennslyvania
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Diagnosis and Treatment of Venous Ulcers LAUREN COLLINS, MD, and SAMINA SERAJ, MD, Thomas Jefferson University Hospital, Philadelphia, Pennslyvania Venous ulcer, also known as stasis ulcer, is the most common etiology of lower extremity ulcer- ation, affecting approximately 1 percent of the U.S. population. Possible causes of venous ulcers include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. The primary risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis, and phlebitis. On physi- cal examination, venous ulcers are generally irregular, shallow, and located over bony promi- nences. Granulation tissue and fibrin are typically present in the ulcer base. Associated findings include lower extremity varicosities, edema, venous dermatitis, and lipodermatosclerosis. Venous ulcers are usually recurrent, and an open ulcer can persist for weeks to many years. Severe complications include cellulitis, osteomyelitis, and malignant change. Poor prognostic factors include large ulcer size and prolonged duration. Evidence-based treatment options for venous ulcers include leg elevation, compression therapy, dressings, pentoxifylline, and aspirin therapy. Surgical management may be considered for ulcers that are large in size, of prolonged duration, or refractory to conservative measures. (Am Fam Physician. 2010;81(8):989-996, 1003. Copyright © 2010 American Academy of Family Physicians.) ▲ Patient information: enous ulcers, or stasis ulcers, to be the primary mechanisms for ulcer A handout on venous ulcers, written by the account for 80 percent of lower formation. Factors that may lead to venous authors of this article, is extremity ulcerations.1 Less com- incompetence include immobility; ineffec- provided on page 1003. mon etiologies for lower extrem- tive pumping of the calf muscle; and venous ityV ulcerations include arterial insufficiency; valve dysfunction from trauma, congenital prolonged pressure; diabetic neuropathy; and absence, venous thrombosis, or phlebitis.14 systemic illness such as rheumatoid arthri- Subsequently, chronic venous stasis causes tis, vasculitis, osteomyelitis, and skin malig- pooling of blood in the venous circulatory nancy.2 The overall prevalence of venous system triggering further capillary dam- ulcers in the United States is approximately age and activation of inflammatory process. 1 percent.1 Venous ulcers are more common in Leukocyte activation, endothelial damage, women and older persons.3-6 The primary risk platelet aggregation, and intracellular edema factors are older age, obesity, previous leg inju- contribute to venous ulcer development and ries, deep venous thrombosis, and phlebitis.7 impaired wound healing.2,14 Venous ulcers are often recurrent, and open ulcers can persist from weeks to many Clinical Presentation and Diagnosis years.8-10 Severe complications include cellu- Determining etiology is a critical step in litis, osteomyelitis, and malignant change.3 the management of venous ulcers. Charac- Although the overall prevalence is relatively teristic differences in clinical presentation low, the refractory nature of these ulcers and physical examination findings can help increase the risk of morbidity and mortal- differentiate venous ulcers from other lower ity, and have a significant impact on patient extremity ulcers (Table 1).2 The diagnosis of quality of life.11,12 The financial burden of venous ulcers is generally clinical; however, venous ulcers is estimated to be $2 billion tests such as ankle-brachial index, color per year in the United States.13,14 duplex ultrasonography, plethysmography, and venography may be helpful if the diag- Pathophysiology nosis is unclear.15-18 The pathophysiology of venous ulcers is not Venous stasis commonly presents as a dull entirely clear. Venous incompetence and ache or pain in the lower extremities, swell- associated venous hypertension are thought ing that subsides with elevation, eczematous April 15, 2010 ◆ Volume 81, Number 8 www.aafp.org/afp American Family Physician 989 Venous Ulcers SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Compression therapy has been proven beneficial for venous ulcer treatment A 2, 7, 10, 22- and is the standard of care. 26, 45 Leg elevation minimizes edema in patients with venous insufficiency and is C 27 recommended as adjunctive therapy for venous ulcers. The recommended regimen is 30 minutes, three or four times per day. Dressings are beneficial for venous ulcer healing, but no dressing has been A 28, 29 shown to be superior. Pentoxifylline (Trental) is effective when used with compression therapy for A 31 venous ulcers, and may be useful as monotherapy. Aspirin (300 mg per day) is effective when used with compression therapy B 32 for venous ulcers. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml. changes of the surrounding skin, and vari- (Table 2).1,2,7,10,19,22-44 In general, the goals of cose veins.2 Venous ulcers often occur over treatment are to reduce edema, improve ulcer bony prominences, particularly the gaiter healing, and prevent recurrence. Although area (over the medial malleolus). The recur- numerous treatment methods are available, rence of an ulcer in the same area is highly they have variable effectiveness and limited suggestive of venous ulcer. data to support their use. On physical examination, venous ulcers are generally irregular and shallow (Figure 1). Conservative Management Granulation tissue and fibrin are often pres- COMPRESSION THERAPY ent in the ulcer base. Other findings include Compression therapy is the standard of lower extremity varicosities; edema; venous care for venous ulcers and chronic venous dermatitis associated with hyperpigmen- tation and hemosiderosis or hemoglobin deposition in the skin; and lipodermatoscle- rosis associated with thickening and fibrosis of normal adipose tissue under skin. A clinical severity score based on the CEAP (clinical, etiology, anatomy, and pathophysi- ology) classification system can guide the assessment of chronic venous disorders. The highest CEAP severity score is applied to patients with ulcers that are active, chronic (greater than three months’ duration, and especially greater than 12 months’ duration), and large (larger than 6 cm in diameter).19,20 Poor prognostic factors for venous ulcers include large size and prolonged duration.21,22 Treatment Figure 1. Venous leg ulcer. Wounds are gener- Treatment options for venous ulcers include ally irregular and shallow. conservative management, mechanical Reprinted with permission from Thomas Jefferson Univer- treatment, medications, and surgical options sity Clinical Image Database. 990 American Family Physician www.aafp.org/afp Volume 81, Number 8 ◆ April 15, 2010 Venous Ulcers Table 1. Common Lower Extremity Ulcers Ulcer type General characteristics Pathophysiology Clinical features Treatment options Venous Most common type; women Venous hypertension Shallow, painful ulcer located Leg elevation, affected more than men; over bony prominences, compression therapy, often occurs in older particularly the gaiter area aspirin, pentoxifylline persons (over medial malleolus); (Trental), surgical granulation tissue and fibrin management present Associated findings include edema, venous dermatitis, varicosities, and lipodermatosclerosis Arterial Associated with cardiac or Tissue ischemia Ulcers are commonly Revascularization, cerebrovascular disease; deep, located over bony antiplatelet medications, patients may present with prominences, round or management of risk claudication, impotence, punched out with sharply factors pain in distal foot; demarcated borders; yellow concomitant with venous base or necrosis; exposure of disease in up to 25 percent tendons of cases Associated findings include abnormal pedal pulses, cool limbs, femoral bruit and prolonged venous filling time Neuropathic Most common cause of Trauma, prolonged Usually occurs on plantar Off-loading of pressure, foot ulcers, usually from pressure aspect of feet in patients topical growth factors; diabetes mellitus with diabetes, neurologic tissue-engineered skin disorders, or Hansen disease Pressure Usually occurs in patients Tissue ischemia and Located over bony Off-loading of pressure; with limited mobility necrosis secondary prominences; risk factors reduction of excessive to prolonged include excessive moisture moisture, sheer, and pressure and altered mental status friction; adequate nutrition Adapted with permission from de Araujo T, Valencia I, Federman DG, Kirsner RS. Managing the patient with venous ulcers. Ann Intern Med. 2003;138(4):327. insufficiency.23,45 A recent Cochrane review contact dermatitis.19 Contraindications to found that venous ulcers heal more quickly compression therapy include clinically sig- with compression therapy than without.45 nificant arterial disease and uncompensated Methods include inelastic, elastic, and inter- heart failure. mittent pneumatic compression. Compres- Inelastic. Inelastic compression therapy sion therapy reduces edema, improves venous provides high working pressure during reflux, enhances healing of ulcers, and ambulation and muscle contraction, but no reduces