Venous leg ulcers

Synonyms

Varicose ulcers.

Epidemiology

Prevalence of all leg ulcers: 1-2% in the general population, 4–5% of individuals older than 80 years. 60-70% occur due to CVI.

Definition

A chronic ulcer on the lower leg between knee and ankle joint resulting from improper functioning of venous valves and advanced chronic venous insufficiency (CVI).

Aetiology & Pathogenesis

The common denominator of vein ulcers is ischaemia of the upper dermis.

Signs & Symptoms

Moderate pain, which improves on elevation (unlike in arterial/mixed ulcers).
Irregular edges, associated oedema, atrophie blanche, pigmentation, associated superficial CVI.

Localisation

Perimalleolar and almost always medial.

Classification

CEAP: Clinical class 5: inactive (healed) ulceration, clinical class 6: active ulceration.

CVI stage III by Widmer: Active or healed ulceration.

Dermatopathology

Biopsies from the edge of the wound should be considered if an ulcer does not respond or responds inadequately to therapy and has an atypical appearance.

Course

Chronic, recurrent.

Complications

Cellulitis (erysipelas) with an ulcer as the entry site. Recurrent cellulitis is often relatively asymptomatic.

Diagnosis

Additional clinical findings: oedema, atrophie blanche, varicose vein(s).
Identification of CVI: duplex sonography.

Differential diagnosis

Vascular, haematological diseases, infections, traumatic/physical, autoimmune, metabolic/endocrine, iatrogenic, neoplasia, congenital.

Prevention & Therapy

Improve general factors, nutrition and physical activity.

Compression therapy, stripping of varicosities, selective vein surgery.

Moist/semi-moist ulcer treatment.

Special

Costs: Venous leg ulcers account for about 1% of health care budgets in western countries.

5.2.1 Venous leg ulcers