Venous Insufficiency Ulcers
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- 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 >$3 billion per year.
- 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).
Up to 80% of leg ulcers are caused by venous disease; arterial disease accounts for 10–25%, which may coexist with venous disease.
- Overall incidence of venous ulcers is 18/100,000 persons.
- Prevalent sex: women > men (20.4 vs. 14.6 per 100,000 for venous ulcer); increased with age for both sexes
- Seen in ~1% of adult population in industrialized countries; increased to 5% 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
- History of leg injury
- 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
- 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.
- Compression hose reduces rates of recurrence compared with no compression.
- Because most ulcers develop following some type of 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.