Venous Insufficiency Ulcers
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- Venous insufficiency disorders include simple spider veins, varicose veins, and leg edema.
- Venous leg ulcers are the most serious consequence of venous insufficiency.
- 500,000 people in the U.S. have chronic venous ulcers, with an estimated treatment cost of <$3 billion/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 person-years.
- Women > Men (20.4 vs. 14.6 per 100,000 for venous ulcer); increased with age for both sexes
- Seen in ~1% of adult population
- 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.
- 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 (1)[A] after symptomatic DVT shown in randomized, controlled trials (RCTs): Prescribe compression hose to be used as soon as feasible for at least 2 years (≥20–30 mm Hg compression).
- Secondary prevention of recurrent ulceration includes compression, correction of the underlying problem, and surveillance. Circumstantial evidence from 2 RCTs showed those who stopped wearing compression hose were more likely to have recurrence (1)[A].
- Since most ulcers develop following some type of trauma, avoiding lower leg trauma may help to prevent ulceration.
- In a diseased venous system, venous pressure in the deep system fails to fall with ambulation, causing venous hypertension.
- Venous hypertension comes from:
- 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, 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
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).