What are the different types of leg ulcers?
Venous ulcers account for up to 90% of leg ulcers. Ulcers are non-healing or poorly-healing open skin wounds. The most common site of venous ulcers is on inner part of the leg just above the ankle. They may also occur on the shin and other areas surrounding the ankle. They are typically not seen on the foot or toes, which are common sites for arterial insufficiency ulcers and diabetic ulcers. Venous ulcers are extremely variable: they can be small or large, shallow or deep, dry and crusty or oozing with drainage, and painless or painful. Venous ulcers are often seen in conjunction with chronic leg swelling and preceded by venous insufficiency skin changes such as:
- Corona Phleb ectatica Paraplantaris– This term literally means, “a crown of dilated veins around or near the foot.” The term is sometimes shortened to just Corona Phlebectatica. In the early stages, this may simply appear as a cluster of spider veins around the inner area of the ankle and foot. This is one of the earliest findings of venous insufficiency and an exam finding that may indicate underlying larger damaged veins even if there are no visible varicose veins. In the later stages, Corona Phlebectatica can appear as severely dilated, dark purple, spider veins (telangectasias) that surround the ankle and/or foot.
- Hemosiderin Hyperpigmentation – Deposits of iron in the form of hemosiderin can result in localized brown discoloration of the skin when there are long-standing varicose vein s and diffuse brown discoloration starting in the lower part of the leg when there is chronic venous insufficiency. Hemosiderin Hyperpigmentation gives the appearance of brown veins in the leg.
- Atrophie Blanche – This term means white areas that are wasting away. Atrophie blanche appears as areas of white scars or ivory-white plaques in the skin that may be slightly depressed and surrounded by redness or pigmentation.
- Venous Dermatitis – This itchy dermatitis is red and scaly and can arise as discrete patches or affect the leg circumferentially. In more severe cases, it may ooze, crust and crack.
- Lipodermatosclerosis – There can be several skin changes associated with Lipodermatosclerosis. The changes in skin color can include pink, red and purple discoloration which eventually turns brown. The skin may become thickened, hardened, tight, and smooth. These areas often become painful.Signs and Symptoms of Venous Ulcers:
- Redness and swelling often present
- Typically occur around the gaiter area (bony spots of the ankles)
- Can be big or small
- Often drain fluid
- Can be painful, but often look a lot worse than you would expect them to feel
- You may or may not have visible varicose veins or leg swelling
What Causes Venous Ulcers?
Skin changes and skin breakdown that result in venous ulcers are triggered by inflammatory mediators when venous hypertension is present. Venous hypertension is increased pressure of blood in the veins of the lower leg, typically caused by venous insufficiency. Venous insufficiency results when there is inadequate return of blood from the legs back to the heart. One cause of venous insufficiency is obstruction from a previous or acute deep vein thrombosis (DVT). If swelling, symptoms or skin changes develop acutely, it could indicate an acute DVT, a medical emergency that requires immediate evaluation.
The most common cause of venous insufficiency is venous reflux from underlying or visible varicose veins that are not functioning normally. In other words, venous insufficiency will result when the functioning veins are unable to compensate for the damaged and refluxing veins. Closure of the damaged veins reroutes blood to the normal ones, relieving venous hypertension and allowing for the healing of venous ulcers, healthier skin and improved venous circulation.
What Can be Done for Venous Ulcers?
The most important step with venous ulcers is an accurate diagnosis. Dr. Campbell has been treating venous ulcers and other related venous issues since 2003. A medical consultation and duplex venous ultrasound are the first steps to diagnosing any venous problem. After a proper diagnosis, addressing the underlying cause of venous ulcers, treatment of the vein disease with sclerotherapy and endovenous thermal ablation treatment, should begin as soon as possible. New England Journal of Medicine recently published a study recommending the immediate treatment of venous ulcers provided quicker healing time. Treatments have been shown to reduce healing time by as much as 50% and to reduce the likelihood of recurrence. As with other vein disease, venous health can be improved with exercise, leg elevation, wearing compression hose/socks, and avoiding prolonged sitting or standing.
Arterial ulcers are the second most common cause of ulcers in the legs, accounting for about 15% of cases. Their cause is related to the arteries and is the opposite of problem with venous ulcers. Arteries carry oxygen and nutrient rich blood to the tissues. When you experience a blockage in the arteries (just like in a heart attack) that blood can’t get to the tissues. This causes the tissues to die, or experience necrosis.
Smoking is one of the biggest risk factors to developing problems with your arteries. Smoking causes plaque build up in your arteries and causes them to get smaller. Smaller arteries mean less blood flow. This is equivalent to suffocating your tissues.
Signs and Symptoms of Arterial Ulcers:
- Often quite painful
- Pale skin
- Pain may be worse at night
- Usually deep with a “punched out” look
- Rarely have drainage
- Walking makes your leg hurt worse, but putting your foot or leg in a dependent position (below your heart, like dangling off the side of the bed) helps to relieve the pain
Treatment of arterial ulcers usually requires surgery with a vascular surgeon to help restore normal blood supply to the area.
It is estimated that 5% of ulcers are related to diabetes. Diabetic ulcers vary slightly in their cause, as it is related to high blood sugar levels instead of being caused from improper circulation. Diabetes is when you have abnormally high levels of blood sugar in your blood stream. This is caused either from your body’s inability to 1) make insulin, or 2) use insulin properly. Insulin acts like a “key” that allows glucose (sugar) entry into the individual cells. Glucose is the fuel, or energy source, for your cells. When insulin isn’t available glucose wanders around banging on your cell’s locked doors. In the process all this excess glucose starts damaging your fragile tissues (the micro-circulation), causing irreparable destruction.
Due to this repeated damage over time you start to lose feeling, especially in your feet. This puts you at risk of developing sores, or ulcers, on your feet from repeated trauma. A known culprit is poor fitting footwear. Regular foot exams by your provider can help detect early signs of damage.
Signs and Symptoms of Diabetic Ulcers
- May be calloused blisters, or red/black in color
- Often painless, unless an infection is present
- Wound may look macerated
Treatment may include debridement (removal of dead tissues), treatment with antibiotics if an infection is present, and good wound care to help keep the wound bed clean to facilitate healing. Properly fitting shoes, not walking around barefoot, and regular foot examinations to assess for damage are essential. In addition, maintaining your diabetes and keeping your blood sugar in control is vital to help with healing and prevent further damage.