Leg ulcers

Created: 25th January 2012 | Last Updated: 20th January 2013

Acknowledgements: This chapter was developed by Dr Brian Malcolm. Brian is a GP principal and trainer in Barnstaple, North Devon and an Associate Specialist in Dermatology.

Introduction

Leg ulcers are of huge socio-economic importance costing the NHS over one billion pounds per year. There are in excess of 100,000 active venous ulcers in the UK at any one time, 80% of these have treatment that is based in the community. A leg ulcer is not a diagnosis; it is a manifestation of an underlying disease process and so the concept should be of the patient with the leg ulcer.

This chapter is set out as follows:

Aetiology
History
Clinical findings
Images
Management
Further images

Aetiology

A working definition of a leg ulcer would be an area of epidermal discontinuity lasting in excess of four weeks:

70-80% of leg ulcers are venous
10-20% are of mixed venous / arterial
10% are arterial
A small number are related to other causes

Venous ulcers

The pathogenesis of venous ulceration is not completely understood but is generally agreed to be the end result of a combination of chronic venous hypertension resulting from venous incompetence and calf muscle insufficiency evidenced by the tissue changes of induration, haemosiderin deposition, fibrosis and reticulate scarring (atrophie blanche) collectively known as lipodermatosclerosis

History

A full medical history needs to be obtained with particular respect given to co-morbid pathologies
The history must include medications, as drugs such as beta-blocker, steroids and non-steroidal anti-inflammatories (NSAID) can all adversely influence ulcer healing
A history of allergy eg to neomycin or lanolin is also important when the choice of appropriate dressings and topical agents is being considered

Clinical findings

Venous
- Almost 90% of venous ulcers originate in the ‘gaiter’ area of the lower leg, most commonly on the medial aspect
- The clinical changes of lipodermatosclerosis support a venous aetiology
- Ulcers are usually shallow, ragged and sloping with variable pain
Arterial
- In contrast, arterial ulcers commonly occur on both the dorsal and plantar aspects of the foot
- Ulcers often have a punched out ‘cliff edge’ appearance with significant levels of pain except when there is co-existent neuropathy, for example in diabetes mellitus
- There may also be signs of arterial compromise such as pallor, loss of hair, nail dystrophy, coldness and diminished capillary refill. Pulses may be impalpable
Neuropathic ulcers
- Develop over pressure areas eg metatarsal heads, sole of foot, balls of toes
- The shape is often irregular, and corresponds to the shape of pressure point that has become exposed
- The edge and base is often clean and may be deep with exposure of bone and tendon
- Neuropathic ulcers may also have features of arterial ulcers if there is co-existent vascular insufficiency

Images

Please click on images to enlarge, or choose to download. Images must only be used for teaching purposes and are not for commercial use. Notice and credit must be given to the PCDS and any other named contributor.

Download	Figure: 1 Atrophie blanche White reticulate scarring
Download	Figure: 2 'Champagne bottle' appearance of lipodermatosclerosis
Download	Figure: 3 Lipodermatosclerosis and venous leg ulcer
Download	Figure: 4 Early venous leg ulcer (arrow) Associated with moderate gravitational eczema
Download	Figure: 5 Venous leg ulcer The ulcer is granulating well at the base, which is a good sign
Download	Figure: 6 Venous leg ulcer
Download	Figure: 7 Venous leg ulcer: close-up Copied with kind permission from Dermatoweb
Download	Figure: 8 Venous leg ulcer Copied with kind permission from Dermatoweb
Download	Figure: 9 Extensive venous ulceration
Download	Figure: 10 Extensive venous ulceration
Download	Figure: 11 Arterial ulcer
Download	Figure: 12 Large neuropathic ulcer
Download	Figure: 13 Neuropathic ulcer on a diabetic foot The lesion has a punched out appearance suggestive of arterial insufficiency

Management

Treatment

Step 1: general

Patients with all forms of ulceration often have very significant co-morbidities such as cardiac failure, hypertension, peripheral vascular disease, diabetes mellitus and connective tissue disease that require a holistic approach if there is to be successful ulcer healing. The cornerstones of wound management are:

Define and treat underlying causes
Strict control of factors affecting healing, for example oedema and infection
Appropriate dressings
Compression therapy where appropriate
Long-term maintenance of successful healing
Provide a patient information leaflet

Step 2: dressings

Do not heal wounds. All dressings, however, have the common goal of achieving an optimal environment for wound healing, which is moist but not macerated, with an optimal ph and temperature, permeable to air, and free of infection, toxins, allergens and irritants. It is beholdent on doctors to achieve a basic understanding of the different categories of dressings in order to have an informed conversation with their nursing colleagues. The dressing types include:

Films eg Opsite ® - these are polyurethane membranes, waterproof, transparent, flexibile and permeable to gas and water vapour. They are non-absorptive and thus not suitable for heavily exuding wounds
Foams eg Lyofoam ® - heat treated polyurethane, very absorbent and insulating. Suitable for a wide range of granulating wounds both flat and cavity
Hydrogels eg Intrasite ® - organic polymers with an increased water content, hydrating and absorbent and capable of absorbing large amounts of exudates
Alginates eg Kaltostat ® - derived from seaweed, very absorbent, hydrating and haemostatic. These can be used in moderate or heavily exuding wounds
Hydrocolloids eg Granuflex ® and Comfeel ® - polymers in fine suspension, absorbent and promote autolysis. Available in pastes, granules and wafers
Inert eg any dressings and gauze - secondary dressings with primarily protective role. These provide an optimal environment for moist wound healing
Proteolytic eg Varidase ® - their major indication is for use in the early healing of sloughy or infected wounds

Step 3: compression thearpy

Compression therapy plays a very important role in the management of venous leg ulcers
There is an array of multi-layer bandaging systems available that are wrapped from the toes / foot to below the knee
Compression techniques can only be used if doppler readings are satisfactory - ABPI readings less then 0.8 would contra-indicate any form of compression therapy except in expert hands and under special circumstances. Extra care has to be taken is patients with diabetes where spuriously high ABPI readings can occur as a result of calcification and incompressibility of the vessels
In the best hands 70% of venous ulcers can be healed in compression bandaging within three months

Step 4: systemic treatments

Evidence regarding the various merits of low-dose aspirin and drugs such as Trental ® (Oxypentifylline) remain contradictory and confused

Complications

Infection

True pathogens such as beta-haemolytic strep have to be treated energetically with appropriate antibiotics

Over-granulation

Can be treated both physically with traditional silver nitrate or with potent topical fluorinated steroids such as Dermovate ® cream

Malignant change

Squamous cell carcinoma is a rare complication of chronic wounds (also known as Marjolin’s ulcer)
More commonly some chronic ‘ulcers’ are misdiagnosed and are indeed primary malignancies. It is important to de-crust persistent lesions in order to identify the possibility of underlying neoplasia
Any suspicious lesion should be referred urgently as a 2 Week Rule to a dermatologist

Eczema / cellulitis

Patients with skin problems of the lower legs are frequently misdiagnosed as having ‘bilateral cellulitis’ and are treated inappropriately with several weeks of systemic antibiotics
Cellulitis is very unlikely to be bilateral and most of these patients instead have a chronic superinfected eczema
Such patients are systemically well and often have a symmetrical bilateral distribution of well-demarcated stable erythema on their legs. If there is doubt a CRP can be useful to exclude the diagnosis of cellulitis
Eczema can be improved with the use of an appropriate topical steroid eg Betnovate-C ® cream until symptoms improve. Patients must not be left on topical steroids indefinitely
If eczematous changes persist consider the possibility of a contact allergic dermatitis to one of the topical treatments / dressings - patch tests may be required

Who to refer

Referral must be considered in the following cases:

Venous ulcers failing to progress at three months or which have not healed by twelve months
All ulcers of an arterial or mixed aetiology - assessment needed for reconstructive surgical / radiological procedures
Failure to adequately control underlying pathologies
Suspected malignant change (2 Week Rule referral to dermatology)
Suspected cases of contact allergic dermatitis
Post-healing - consideration should be given to the referral for further investigations of venous leg ulcers to see if surgical intervention would reduce the risk of re-ulceration. Such a referral would depend on local resources, and is particularly relevant for patients developing ulcers from a young age

Most patients needing referral should be directed to community leg ulcer (tissue viability) clinics or dermatology departments. However, patients in groups 2 or 6 should be referred to vascular surgeons. And remember that leg ulcers can result from diverse pathology, the images below are just a few examples.

Further images

Download	Figure: 1 Dressings
Download	Figure: 2 Contact allergic dermatitis to dressings Always consider a contact allergic dermatitis to topical treatments or dressings in patients whose symptoms suddenly deteriorate
Download	Figure: 3 The same patient as above - ten days after topical steroids
Download	Figure: 4 Crusted lesion on lower leg
Download	Figure: 5 Same patient as above Lesion de-crusted to reveal an underlying SCC
Download	Figure: 6 SCC of toe - treated as an ulcer for four years
Download	Figure: 7 Marjolin's ulcer A chronic venous ulcer that had transformed in to an SCC. The edge of the lesion had grown and become more pronounced over several months
Download	Figure: 8 Ulcerating necrobiosis lipoidica
Download	Figure: 9 Ulcer associated with rheumatoid arthritis
Download	Figure: 10 Artefactual ulcer The patient had done this to themselves
Download	Figure: 11 Leischmaniasis