Description

• 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

Epidemiology

80% of leg ulcers are caused by venous disease versus 10–25% arterial disease.

Incidence

• The overall incidence of venous ulcers is 18/100,000 persons; more common in women than 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.

Prevalence

• 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.

Genetics

• Autosomal dominant trait with variable penetrance with no specific gene or gene set identified
• Forkhead box protein C2 identified as possible marker in patients with varicose veins

Risk Factors

• 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
• Smoking, prolonged standing, pregnancy

General Prevention

• After DVT: compression hose for at least 2 years (≥20 to 30 mm Hg compression)
• For recurrent ulceration: compression, treat underlying problem, exercise.
• Avoid triple antibiotic ointment, including anything containing neomycin sulfate.