Venous Insufficiency Ulcers

Venous Insufficiency Ulcers is a topic covered in the 5-Minute Clinical Consult.

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Basics

  • Venous insufficiency disorders include simple spider veins, varicose veins, and leg edema.
  • In the United States, 23% of adults have varicose veins, an estimated 22 million women and 11 million men.
  • Venous leg ulcers are the most serious consequence of venous insufficiency.
  • Venous leg ulcers are a type of chronic wound affecting up to 1% of adults in developed countries at some point during their lives.
  • 500,000 people in the United States have chronic venous ulcers, with an estimated treatment cost of >$2.5 billion per year.

Description

  • Full-thickness skin defect with surrounding pigmentation and dermatitis
  • Most frequently located in ankle region of lower leg (“gaiter region”)
  • Present for >30 days and fails to heal spontaneously
  • May only have mild pain unless infected
  • Other signs of chronic venous insufficiency include edema/brawny edema and chronic skin changes (i.e., hyperpigmentation and/or fibrosis).

Epidemiology

Up to 80% of leg ulcers are caused by venous disease; arterial disease accounts for 10–25%, which may coexist with venous disease.

Incidence
  • Overall incidence of venous ulcers is 18/100,000 persons.
  • Prevalent sex: women > men (20.4 vs. 14.6/100,000 for venous ulcer); increased with age for both sexes
Prevalence
  • Seen in ∼1% of adult population in industrialized countries; increased to 4% in patients ≥80 years old
  • Prevalence studies only available for Western countries
  • Point prevalence underestimates the extent of the disease because ulcers often recur.
  • 70% of ulcers recur within 5 years of closure.

Etiology and Pathophysiology

  • In a diseased venous system, venous pressure in the deep system fails to fall with ambulation, causing venous hypertension.
  • Venous hypertension comes from the following:
    • Venous obstruction
    • Incompetent venous valves in the deep or superficial system
    • Inadequate muscle contraction (e.g., arthritis, myopathies, neuropathies) so that the calf pump is ineffective
  • Venous pressure transmitted to capillaries leading to venous hypertensive microangiopathy and extravasation of RBCs and proteins (especially fibrinogen)
  • Increased RBC aggregation leads to reduced oxygen transport, slowed arteriolar circulation, and ischemia at the skin level, contributing to ulcers.
  • Leukocytes aggregate to hypoxic areas and increase local inflammation.
  • Factors promoting persistence of venous ulcers
    • Prolonged chronic inflammation
    • Bacterial infection, critical colonization

Risk Factors

  • History of leg injury
  • Obesity
  • Congestive heart failure (CHF)
  • History of deep venous thrombosis (DVT)
  • Failure of calf muscle pump (e.g., ankle fusion, inactivity) is a strong independent predictor of poorly healing wounds.
  • Previous varicose vein surgery
  • Family history

General Prevention

  • Primary prevention after symptomatic DVT: Prescribe compression hose to be used as soon as feasible for at least 2 years (≥20 to 30 mm Hg compression).
  • Secondary prevention of recurrent ulceration includes compression, correction of the underlying problem, and surveillance.
  • Circumstantial evidence from two RCTs showed those who stopped wearing compression hose were more likely to recur.
  • Because most ulcers develop from trauma, avoiding lower leg trauma may help to prevent ulceration.

Commonly Associated Conditions

Up to 50% of patients have allergic reactions to topical agents commonly used for treatment.

  • Contact sensitivity was more common in patients with stasis dermatitis (62% vs. 38%).
  • Avoid neomycin sulfate in particular (including triple antibiotic ointment).

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