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venous stasis ulcer

Ulceration associated with ambulatory venous hypertension. Etiology: - chronic venous insufficiency - incompetence of deep vein valves - deep vein thrombosis Clinical manifestations: - ulcer is generally not painful unless secondarily infected - symptoms range from not painful to significant pain [5] - generally between knee & ankle, medial along the course of the long saphenous vein, especially the region of the medial malleolus - often associated aching & swelling of lower leg aggravated by standing - untreated ulcers generally have exudate - exudate is generally serosanguineous or purulent - signs of secondary infection - fecal odor - surrounding erythema - fever - surrounding skin often has edema & brown discoloration (hemosiderin) - varicosities are generally present - occasional induration & inflammation of the dermis & subcutaneous fat For staging of ulcers see pressure (decubitus ulcer) * images [18,19] Laboratory: - wound cultures generally reveal polymicrobial flora - generally not helpful - culture from base of wound after cleansing if compelled to do so - blood cultures if systemic infection suspected - ultrasound-doppler if suspecting deep vein thrombosis Special laboratory: - assess arterial status prior to application of compression - ankle-brachial index - not necessary if pulses normal & arterial ulcer not suspected Complications: - osteomyelitis Differential diagnosis: - arterial ulcer (for comparison see [19]) - neuropathic ulcers occur primarily on plantar aspect of foot - pyoderma gangrenosum is painful Management: - address underlying chronic venous insufficiency - diuresis to treat congestive heart failure - necrotic tissue must be removed to promote healing - venous compression to reduce venous stasis & edema - elastic stockings - zinc oxide bandages (Unna boot) for venous leg ulcers on the medial malleolus - elastic wraps (ACE bandage) - colloid wrap (Duoderm) - treatment of choice [23] - dressing - hydrocolloid dressings perform no better than simple non-adherant dressings [4] - moist wound surface may promote wound healing - wet to dry dressing to remove necrotic tissue followed by moist saline dressings - dry dressing disrupts formation of granulation tissue when removed [5] - betadine, hydrogen peroxide, Dakin's solution (KOCl) & acetic acid inhibit wound healing by cytotoxicity - silver sulfadiazine [8] - treat systemic infection & cellulitis - systemic antibiotics (see cellulitis) - reserve systemic anibiotics for clinically infected ulcers [5] - calcipotriene (Dovonex) - pentoxifylline in addition to venous compression [3,5] - 400-800 mg PO TID - cilostazol (Pletal) may be alternative - addition of exercise to compression of benefit [25] - aspirin 300 mg/day of benefit [13] - aspirin 150 mg/day of no benefit [23] - good nutritional support - maintain adequate circulation - surgery - selected patients who fail medical management - early endovenous ablation of superficial venous reflux (within 2 weeks) reduces time to ulcer healing (56 vs 82 days for venous compression) [24] - early endovenous ablation lowers incidence of recurrent ulcers [26] - investigational therapy - autologous platelet-rich plasma therapy [25] - spray-on allogeneic skin cells may be of benefit - simvastatin 40 mg/day reportedly heals 100% of stasis ulcers <= 5 cm in size in 10 weeks (vs 46% of controls) [11] - topical beta-blocker may be of benefit [12] - electromagnetic therapy of no benefit [14] - patient education - avoid heating pads & ice packs to prevent thermal injury - avoid prolonged standing - avoid sitting with legs crossed - ambulate intermittently - use moisturizer: Eucerin or alpha Keri on surrounding skin

Related

arterial ulcer neuropathic ulcer pressure ulcer (decubitus ulcer, bedsore) venous stasis; venous hypertension

General

cutaneous ulcer chronic skin disease (chronic dermatologic disorder, chronic dermatopathy, chronic dermatosis)

References

  1. nlmpubs.nlm.nih.gov/hstat/ahcpr/
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 987
  3. Prescriber's Letter 9(7):39 2002
  4. Palfreyman S et al, Dressings for venous leg ulcers: Systematic review and meta-analysis. BMJ 2007, 335:244 PMID: 17631512
  5. Medical Knowledge Self Assessment Program (MKSAP) 15, 16. 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021.
  6. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
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  8. Miller AC, Rashid RM, Falzon L, Elamin EM, Zehtabchi S. Silver sulfadiazine for the treatment of partial-thickness burns and venous stasis ulcers. J Am Acad Dermatol. 2012 May;66(5):e159-65 PMID: 20724028
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  10. Kunimoto BT. Management and prevention of venous leg ulcers: a literature- guided approach. Ostomy Wound Manage. 2001 Jun;47(6):36-42, 44-9. PMID: 11890083
  11. Evangelista MT et al. Simvastatin as a novel therapeutic agent for venous ulcers: A randomized, double-blind, placebo-controlled trial. Br J Dermatol 2014 Feb 7 PMID: 24506834 http://onlinelibrary.wiley.com/doi/10.1111/bjd.12883/abstract
  12. Lev-Tov H1, Dahle S, Moss J, Isseroff RR. Successful treatment of a chronic venous leg ulcer using a topical beta-blocker. J Am Acad Dermatol. 2013 Oct;69(4):e204-5 PMID: 24034405
  13. Layton AM1, Ibbotson SH, Davies JA, Goodfield MJ. Randomised trial of oral aspirin for chronic venous leg ulcers. Lancet. 1994 Jul 16;344(8916):164-5. PMID: 7912767
  14. Aziz Z, Cullum N, Flemming K. Electromagnetic therapy for treating venous leg ulcers. Cochrane Database Syst Rev. 2013 Feb 28;2:CD002933 PMID: 23450536
  15. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
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  19. London Health Sciences Centre. (image) Venous Stasis & Arterial Ulcer Comparison. http://www.lhsc.on.ca/Health_Professionals/Wound_Care/venous.htm
  20. Richmond NA, Maderal AD, Vivas AC Evidence-based management of common chronic lower extremity ulcers. Dermatol Ther. 2013 May-Jun;26(3):187-96 PMID: 23742279
  21. Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ. 2006 Feb 11;332(7537):347-50 PMID: 16470058
  22. Rothaus C Evaluation and Management of Lower-Extremity Ulcers. NEJM Resident 360. Oct 19, 2017 https://resident360.nejm.org/content_items/evaluation-and-management-of-lower-extremity-ulcers - Singer AJ, Tassiopoulos A, Kirsner RS. Evaluation and management of lower-extremity ulcers. N Engl J Med. 2017;377(16):1559-1567 PMID: 29045216 https://www.nejm.org/doi/10.1056/NEJMra1615243
  23. Jull A, Wadham A, Bullen C, Parag V, Kerse N, Waters J. Low dose aspirin as adjuvant treatment for venous leg ulceration: Pragmatic, randomised, double blind, placebo controlled trial (Aspirin4VLU). BMJ 2017 Nov 24; 359:j5157 PMID: 29175902 Free PMC Article
  24. Gohel MS, Heatley F, Liu X A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. N Engl J Med. April 24, 2018 PMID: 29688123 http://www.nejm.org/doi/full/10.1056/NEJMoa1801214
  25. Jull A, Slark J, Parsons J. Prescribed Exercise With Compression vs Compression Alone in Treating Patients With Venous Leg Ulcers. A Systematic Review and Meta-analysis. JAMA Dermatol. Published online October 3, 2018 PMID: 30285080 https://jamanetwork.com/journals/jamadermatology/fullarticle/2705273 - Kirsner RS Exercise for Leg Ulcers "Working Out" the Nature of Venous Ulcers. JAMA Dermatol. Published online October 3, 2018 PMID: 30285045 https://jamanetwork.com/journals/jamadermatology/fullarticle/2705268
  26. Gohel MS et al. Long-term clinical and cost-effectiveness of early endovenous ablation in venous ulceration: A randomized clinical trial. JAMA Surg 2020 Dec; 155:1113 PMID: 32965493 PMCID: PMC7512122 Free PMC article https://jamanetwork.com/journals/jamasurgery/fullarticle/2770717
  27. Qu W, Wang Z, Hunt C et al The Effectiveness and Safety of Platelet-Rich Plasma for Chronic Wounds. Mayo Proc 2021. July 3 PMID: 34226023 https://www.mayoclinicproceedings.org/article/S0025-6196(21)00166-X/fulltext
  28. Lim CS, Baruah M, Bahia SS. Diagnosis and management of venous leg ulcers. BMJ. 2018;362:k3115 PMID: 30108047 https://www.bmj.com/content/362/bmj.k3115
  29. O'Meara S, Cullum NA, Nelson EA et al. Compression for venous leg ulcers. Cochrane Database Sys Rev. 2012 Nov 14;11(11):CD000265. PMID: 23152202 PMCID: PMC7068175 Free PMC article https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000265.pub3/full