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 >$2.5 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.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
- 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
- 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.
- 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).