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. This is often caused by defective valves in the veins, which cause the venous blood to pool, leading to dilated veins ( varicosis) and eventually venous ulcers. Another cause of venous insufficiency is post-thrombotic syndrome - a situation following a deep venous thrombosis ( blood clot) that may have occurred many years earlier.
Venous leg ulcers usually appear in the distal 1/3 of the leg and often on the medial side. They are generally quite superficial with irregular edges. In the wound bed, you will often find a mix of fibrine, yellow necrotic tissue, and possibly even black necrotic tissue.
Venous ulcers tend 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. This is called a mixed ulcer or an arterial-venous ulcer.
Compression treatment is the most crucial element when treating venous leg ulcers. This can be done with medical-grade compression stockings when the ulcers are small. It is often impractical to use stockings with more extensive ulcers, and commonly elastic compression bandages are used until the ulcers have healed. Alternatively, velcro compression devices can be used. This can be a financial challenge in a healthcare setting with limited resources. Compression devices, be it stockings or elastic bandages, are costly, and it is difficult to find cheap alternatives.
Remember - patients with venous insufficiency should use compression for the rest of their lives. Our job as health care workers is to explain to the patient why this is important and encourage them to follow our recommendations.
In Africa, a significant 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 compression level, you may have to accept that they use 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 compression intensity can be gradually increased. This may probably help with compliance!
If the patient has a venous ulcer that doesn't 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 ulcers, for instance, Buruli ulcer types.
When it comes to the choice of wound dressing, the most critical 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 increase in size is extreme maceration of the skin edges. You usually need super-absorbent dressings at the start to get this under control. After a week or so, the exudate levels typically decrease - as long as you are using compression, you can either switch to a cheaper dressing or prolong dressing change intervals.
Note that sometimes 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 you may have to use vaseline as a barrier product if you don't have zinc paste available.
As a rule of thumb, venous ulcers are treated at the primary health care level. If the ulcer does not improve within six 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. Note the somewhat irregular edges and that the ulcer is fairly superficial. Note also 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 who 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 to 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 aging process but can start earlier due to genetic predisposition. Early signs of venous insufficiency are swelling of the legs and, later on, the development of varicosis. Note that the varicose veins are not always easily visible. Sometimes the reason for venous insufficiency 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 happened. The thrombosis can then cause a permanent blockage of the veins leading to a condition called a 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 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. The valves are not closing correctly in the illustration on the right, and blood can run in reverse, especially when standing 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 (AFV) 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 modified several times since. The last version is CEAP 3.
The CEAP classification is important when we, for example, compare patients in clinical studies. It 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 recommend which products to use according to which CEAP classification the patient's condition relates to. We have written more on this in the chapter dedicated to compression treatment.
The CEAP classification is based on the clinical changes which you see in the skin (C = Clinic), the etiological causes of the venous insufficiency(E = Etiology), anatomical changes (A= Anatomical), and the pathophysiology behind the venous insufficiency(P= Pathophysiology).
Many health 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, A, and 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 we will not present this here to avoid confusion. 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 earlier ulcer but 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 within 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 make an exact diagnosis.
Figure 1 SIGN (Scottish Intercollegiate Guidelines Network), together with the NHS in the UK, has 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