Take home messages about venous leg ulcers
Venous leg ulcers are seen in patients with venous insufficiency. In these patients the blood flow upwards from the legs is impaired in one way or another. often this is caused by defect valves in the veins which cause the venous blood to pool leading to dilated veins ( varicosis) and in the long run often venous ulcers. Other causes for venous insufficiency are for example post thrombotic syndrome - a situation following a deep venous thrombosis ( blood clot) that may have occured many years earlier.
Venous leg ulcers usually appear in the distal 1/3 of the leg and often on the medial side. They are generelly quite superficial with irregular edges. Quite often you will find a mix of fibrine, yellow necrotic tissue and possibly even black necrotic tissue in the wound bed.
Venous ulcers have a tendency to have a fairly large surface area, have a high amount of exudate and are often quite painful.
Patients with venous ulcers usually find relief from pain when holding the affected limb elevated. If a patient prefers holding the affected leg downward you should suspect that the arterial blood flow also may be impaired aswell as the venous blood flow. This is called a mixed ulcer or an arterial-venous ulcer.
Compression treatment is the most important element when treating venous leg ulcers. When the ulcers are small this can be done with medical grade compression stockings. With bigger ulcers it is often impractical using stockings and normally elastic compression bandages are used until the ulcers have healed. Alternatively velcro compression devices can be used. In a healthcare setting with limited resources this can be a financial challenge. Compression devices, be it stockings or elastic bandages are costly and it is difficult to find cheap alterantives.
Remember - patienst with venous insufficiency should use compression for the rest of their lives. It is our job as health care workers to explain to the patient why this is important and to encourage them to follow our recommendations.
In Africa a major factor causing patients not to use compression is obviously the cost of compression devices . Also- many patients feel that it is uncomfortable to use compression. If this is the case the compression may be too tight or not the ideal compression device for the specific patient. Velcro compression devices have the advantage that the patient himself can adjust the intensity according to discomfort level.
Remember: Some compression is better than none! If the patient does not tolerate a normal level of compression you may have to accept that he/she uses lower compression.
It is always a good idea to start with weak compression so that the patient gets used to it. After a few days the intensit of the compression can be gradually increased. This may probably help with compliance!
If the patient has a venous ulcer that doesnt want to heal even though the compression treatment seems adequate something is wrong! You will have to look at differential diagnoses. Often there may be an arterial component at the same time ( mixed ulcer!) or even a malign ulcer ( for example squamous carcinoma). Other relevant differential diagnoses are tropical ulcer for example Buruli ulcer types.
When it comes to choice of wound dressing the most important factor to consider is the amount of exudate that comes from the wound. The exudate from these ulcers is very aggressive to the surrounding skin and we see very often that the reason for the ulcers increasing in size is extreme maceration of the skin edges. Very often you need super-absorbant dressings in the start to get this under control. After a week or so the exudate levels normally decrease - as long as you are using compression- and you can either switch to a cheaper dressing or prolong dressing change intervals.
Note that sometimes especially larger venous ulcers might have so much exudate that even a superior dressing cannot handle these amounts and the only solution is to change the dressing several times a day!
Protecting the skin edges with barrier products is very important with venous ulcers. Zinc paste is a good barrier product but if you cant get this you may have to use vaseline as a barrier product.
As a rule of thumb venous ulcers are treated at primary health care level. If the ulcer does not improve within 6 weeks at the latest you should try to refer the patient to the next level of care for a second opinion.
Figure 1 A classic venous ulcer on the medial side of the lower third of the left leg. Notie the somewhat irregular edges and that the ulcer is fairly superfiscial. Note alos the darkish pigmentation of areas of the leg. This is known as hemosiderin and represents iron deposits in the skin due to leakage from the veins over time. These pigmentations are very common in patients that have had venous insufficiency for several years. In dark skin hemosiderin can be harder to detect.
Why do venous ulcers develop?
Venous ulcers are among the most common type of chronic wounds we encounter in clinical practice. They develop because of a malfunctioning of the veins that transport blood from the end of the foot up towards the heart. This venous malfunctioning is also called venous insufficiency.
In most cases the reason for the venous insufficiency is leaking valves in the veins. This is a normal process of aging but can start at earlier age due to genetic predisposition. Early signs of venous insufficiency are swelling of the legs and later on development of varicosis. Note that the varicose veins not always are easily visible. Sometimes the reason for venous insuffiiciency is a previous deep venous thrombosis. This may have been a blood clot in a deep vein in the thigh or groin area which may have happened many years ago, possibly even without the patient being aware that this happend. The thrombosis can then have caused a permanent blokkage of the veins leading to a condition called postthrombotic syndrome. This is usually characterized by edema in the affected extremity, brownish pigmentation (hemosiderin) and ulcers in the late stage.
It is rare that venous ulcers simply appear just because a patient has venous insufficiency. Usually these wounds are secondary to some sort of skin injury, quite often only a minor injury. However, once the skin has been broken it will not heal and often increases in size due to the venous insufficiency.
Figure 2 The illustration on the left shows how healthy valves in a vein close when blood attempts to flow downward. In the illustration on the right we see that the valves are not closing properly and blood can run in reverse especially when we stand upright. This increases the pressure in the veins and leads to varicose veins and edema in the lower extremities.
CEAP classification of venous insufficiency
There are several types of vein disorders and to systematize these the American Venous Forum (AVF) published a classification system called CEAP in 1994. The name CEAP classification stands for Clinical (C), Etiological (E), Anatomical (A), and Pathophysiological (P)This has become an international standard and has been modofoed several times since. The last version is CEAP 3.
The CEAP calssification is important when we for example compare patients in clinical studies. It has also has relevance to clinical decision making for instance when we choose a medical grade compression stocking. When buying stockings from leading producers like Jobst® eller Sigvaris® they make recommendations for which products to use according to which CEAP classification the patients condition relates to. We have written more on this in the chapter dedicated to compression treatment.
The CEAP klassifikasjonen is based on the clinical changes which you see in the skin (C = Clinic), the etiological causes of the vebnous insufficiency(E = Etiology), anatomical changes (A= Anatomical) and the pathofysiology behind the venous insufficiency(P= Pathophysiology).
Many healtch care providers will find the CEAP classification somewhat complicated. The first part - the"C" in CEAP is the easy part. here you only need your eyes to see which category is in. But the E,Aand P parts require good clinical knowledge/experience and access to for example a doppler ultrasound for a thorough evaluation.
There is even a more advanced CEAP classification available ( aptly called Advanced CEAP classification) but to avoid confusion we will not present this here. The " basic" version ( called CEAP basic) is adequate for most situations.
Table 1 The first part of the CEAP classification (C) is about what you can visualize on the skin with your eyes. The higher the number- the more serious the condition. A patient who has had an ulcer earlier but which has healed is classed as C5 - so this is a serious condition. Many patients who have had venous ulcers previously will get a new ulcer iwthin some years.
Table 2 E,A og P part of the CEAP klassifikasjonen. To evaluate these parameters you need to be quite experienced Also, you will need access to technical aids like an ultrasound machine to be able to make an exact diagnosis.
Figure 1 SIGN (Scottish Intercollegiate Guidelines Network) together with the NHS in the UK have published a very useful national clinical guideline for the management of venous ulcers. Click on the picture above to get to the document. However, we recommend that you read the rest of our chapters on venous ulcers first.
Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensu Committee on Chronic Venous Disease. J Vasc Surg 1995;21:635-45
Eklof B, Rutherford RB, Bergan JJ, Carpentier PH, Glovicski P, Kistner RL, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Sur 2004;40:1248-52
Meissner et al. Primary chronic venous disorders. J Vasc Surg 2007;46:54S-67S