Venous Insufficiency Ulcers
- Venous insufficiency is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart and causing stasis.
- Signs of chronic venous insufficiency include edema, bulging veins, hyperpigmentation, dermatitis, woody fibrosis, lipodermatosclerosis, and ulcers.
- Venous stasis ulcers are the most serious consequence of chronic venous insufficiency.
- Venous stasis ulcers affect up to 3% of adults in developed countries at some point during their lives.
- The annual estimated treatment cost of chronic venous ulcers is $2.5 to $3.5 billion dollars per year.
- Irregular and shallow skin defect with surrounding hyperpigmentation and well-defined borders
- Most frequently located in the lower leg or ankle over the bony prominences
- Present for >30 days and fails to heal spontaneously
- May only have mild pain unless infected
80% of leg ulcers are caused by venous disease vs. 10–25% arterial disease
- The overall incidence of venous ulcers is 18/100,000 persons; more common in women than in men (20.4 vs. 14.6/100,000), incidence increases with age in both men and women.
- >20,000 patients are newly diagnosed with venous ulcers in the United States yearly.
- Venous ulcers are seen in ~1% of the adult population and up to 4% in adults ≥80 years old in industrialized countries.
- 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)
- Venous pressure transmitted to capillaries leads 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 the hypoxic areas and increase local inflammation.
- Prolonged chronic inflammation and bacterial infection promote the persistence of ulcers.
- History of leg injury
- Age >55 years
- High BMI
- Congestive heart failure (CHF)
- History of deep venous thrombosis (DVT)
- Failure of the calf muscle pump (e.g., ankle fusion, inactivity)
- Previous varicose vein surgery or ulcers
- Prolonged standing
- Family history
- Primary prevention after symptomatic DVT: Prescribe compression hose as soon as feasible, to be used 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.
- Encourage exercise to improve muscle pump function.
Commonly Associated Conditions
Up to 50% of patients have allergic reactions to topical agents commonly used for treatment.
- Avoid triple antibiotic ointment, including anything containing neomycin sulfate.
There's more to see -- the rest of this topic is available only to subscribers.
Domino, Frank J., et al., editors. "Venous Insufficiency Ulcers." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2020. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117024/all/Venous_Insufficiency_Ulcers.
Venous Insufficiency Ulcers. In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2020. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117024/all/Venous_Insufficiency_Ulcers. Accessed May 29, 2023.
Venous Insufficiency Ulcers. (2020). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (27th ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117024/all/Venous_Insufficiency_Ulcers
Venous Insufficiency Ulcers [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2020. [cited 2023 May 29]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117024/all/Venous_Insufficiency_Ulcers.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Venous Insufficiency Ulcers ID - 117024 ED - Domino,Frank J, ED - Baldor,Robert A, ED - Golding,Jeremy, ED - Stephens,Mark B, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117024/all/Venous_Insufficiency_Ulcers PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -