Venous Leg Ulcer

Hadar Lev-Tov; Arturo Robles-Tenorio; Jorge Ocampo-Candiani; Mark A. Dreyer

Venous Leg Ulcer

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Free Review Questions

Continuing Education Activity

Venous leg ulcers are late manifestations of chronic venous insufficiency that can cause disability and serious complications. The elderly are more commonly affected. As the global population becomes older, the disease has shown a worldwide growing incidence. This activity reviews the diagnostic and therapeutic approach for venous stasis ulcers and highlights the role of the interprofessional team in evaluating and treating patients with this condition.

Objectives:

Identify the risk factors associated with the development of venous leg ulcers.
Explain the pathophysiology of chronic venous hypertension and venous leg ulceration.
Describe the clinical features of venous leg ulcers.
Outline some interprofessional team strategies to improve outcomes for patients with venous leg ulcers.

Introduction

Venous leg ulcers (VLUs) are late indicators of chronic venous insufficiency (CVI) and venous hypertension.[1][2][3][4] In normal conditions, calf muscle contraction and intraluminal valves promote prograde flow while preventing blood reflux.[5] However, when retrograde flow, obstruction, or both exist, the resultant chronic venous hypertension is responsible for the dermatologic and vascular complications that culminate in the formation of a VLU.[6]

VLUs are a costly medical problem with a high toll on worldwide healthcare systems.[7][8][9] In the United States, the Medicare and commercial insurance annual cost for VLU patients ascends to $18,986 and $13,653, respectively.[10] Together, these represent an annual burden of $14.9 billion for the United States payers, a considerable increase from a previous $1 billion estimate.[11] The situation may worsen as the aging, obese, and sedentary population increases globally, with an expected incidence rise for CVI and VLUs.[12] This problem demands a swift, coordinated, interdisciplinary call to action from all stakeholders.

Etiology

Although CVI is a well-known precipitant for VLU development, ulceration occurs rarely (5.1%) for unclear reasons.[13] CVI may develop due to blood reflux, obstruction, or a combination of both mechanisms, causing macro- and micro-circulatory disfunction.[5] The increased intraluminal pressure causes protein extravasation and fibrin cuff formation, which impedes the diffusion of oxygen and growth factors, and also activates the inflammatory response.[14][15]

At a cellular level, mast cell degranulation, leukocyte recruitment, increased matrix metalloproteinase inhibitors and prostacyclin, the acquisition of a non-contractile secretory phenotype by smooth muscle cells, and fibroblast differentiation into myofibroblasts participate in vein wall remodeling and varix formation. The proinflammatory microenvironment is maintained by M1 macrophages, mainly through the release of IL-1α, IFN-γ, and TGF-β1. Ultimately, chronic inflammation and incompetent blood flow favor thrombus formation, causing further fibrosis and valvular destruction.[16] Together, this inflammatory cascade of events impairs healing processes, which results in ulcer formation upon wounding.

The majority of risk factors for the development of VLUs are non-modifiable, and patients often present more than one. These involve a family history of CVI, advanced age, female sex, previous thrombosis or pulmonary embolism, multiparity, lipodermatosclerosis, musculoskeletal and joint disease.[5][1] Modifiable risk factors such as obesity and sedentarism are also associated with venous disease.[17][18][19]

Genetics traits may be an additional predisposing factor, apparently presenting as an autosomal dominant trait with variable penetrance.[14][1] However, a specific gene or gene set has not been determined. Forkhead box C2, located on chromosome 16q24, is a candidate marker found in subjects with varicose veins.[20]

Compared with healing VLUs, the gene expression profile of non-healing VLUs showed upregulation of secreted frizzled-related protein 4, branched-chain aminotransferase 1, dermatopontin, cytochrome P450, and 17 B hydroxysteroid dehydrogenase genes, which are involved in inflammation control, Wnt signaling, cell growth, extracellular matrix assembly, and steroidogenesis.[21][22][23][24] On the other side, collagen differentiation and epidermal repair genes such as collagen type 13α1, collagen 27α1, keratin 14, keratin 16, and heparin-binding epidermal growth factor were notoriously downregulated. Besides these, single nucleotide polymorphisms of high iron Fe, ferroportin 1, and matrix metalloproteinase 12 indicate venous ulcer development susceptibility.[25][26][22] In another gene expression study, VLUs treated with a bioengineered bilayered living cellular construct skin substitute displayed a shift from a chronic non-healing inflammatory profile to acute healing inflammation, highlighting the negative effects of chronic inflammation in wound healing.[27]

Epidemiology

VLUs are the most common type of lower extremity chronic wounds.[28] It is estimated that 1 to 3% of the elderly population are affected in the United States and Europe.[29] An epidemiological survey from Asia, Eastern Europe, Latin America, and Western Europe showed that 2.21% out of 99,359 CVI patients had an active or healed VLU when visiting their primary care physician for various reasons. Individual regional rates were reported in 1.27%, 2.87%, 3.97%, and 1.67%, respectively.[30]

The overall incidence is higher for females than males, although the exact number is hard to establish as it depends on the cohort and place of study.[29][31] The average time from CVI diagnosis to ulceration is 5 years, according to a 25-year population study.[32] Indeed, another report demonstrated that in people with CVI, the 3-year risk for the first ulceration was 4.49%, ascending to 4.93% at the 5-year follow-up.[13]

Histopathology

Unless another diagnosis is suspected, a biopsy is not warranted.[33][34] If performed, specimens should be obtained from the wound edge and the base of the ulcer.

History and Physical

Identification of risk factors on clinical history helps to distinguish VLUs from other causes of lower extremity non-healing wounds. Patients with CVI and VLUs often refer pruritus with or without a rash, aching pain in the gaiter area, evening pedal edema, and night cramps.[35][36]

Early CVI physical findings must be identified on examination. The initial manifestations are telangiectases and reticular veins.[5] Varicose veins, brown-orange hyperpigmentation, chronic leg edema, stasis dermatitis, atrophie blanche, and lipodermatosclerosis are late indicators of venous insufficiency. VLUs typically affect the distal end of the legs over the medial aspect, appearing as shallow, irregular, well-defined ulcers with fibrinous material on the base.[37][38]

The clinical, etiological, anatomical, and pathophysiological (CEAP) classification is used to document these findings for therapeutic and research purposes.[39] Other less used instruments are the Venous Clinical Severity Score and the Widmer’s classification.[40][41]

Evaluation

Clinical assessment should describe the ulcer area, depth, edges, wound base, signs of infection, and peripheral skin changes.[42][34][33] Palpation of distal pulses and ankle-brachial pressure index (ABPI) is used to evaluate adequate arterial blood flow, since approximately 20% of VLU patients have coinicident arterial disease. ABPI is obtained by dividing the systolic ankle pressure by the systolic arm pressure taken in the supine position. An ABPI > 1.00 to 1.3 is considered normal. Below this, cut-off values are used to classify disease severity and guide the appropriateness of compression therapy (Table 1). Paradoxically, an ABPI > 1.3 appears in patients with significant vascular calcification, indicating the need for urgent referral to a vascular specialist.[43]

Table 1. Ankle-brachial pressure index[43]

Ankle-brachial pressure index	Arterial circulation	Compression treatment
> 1-1.3	Normal	Apply compression
= 0.8-1.0	Mild peripheral disease	Apply compression with caution
≤ 0.8-0.6	Significant arterial disease	Use modified compression with caution and refer to a vascular specialist
< 0.5	Critical ischemia	Do not compress and urgently refer to a vascular specialist

Color-flow duplex ultrasound is another inexpensive, non-invasive, and highly informative diagnostic test, particularly useful for superficial vein assessment.[34][44] The technique can identify thrombi presence and valve incompetence, which is declared when reflux time is > 0.5 s.[45] Computed tomography and magnetic resonance imaging are preferred for deeper vessels since they are often harder or impossible to evaluate with ultrasound. Phlebography, plethysmography, and phlebodynamometry are less used methods due to inferior accuracy and associated risks.[46][47]

Treatment / Management

The standard of care for VLUs relies on two strategies: compression therapy and direct wound management.[36] Reducing leg edema is crucial for the effectiveness of wound closure.[33]

There are numerous conservative alternatives aimed at improving venous hypertension, such as medical compression, intermittent pneumatic compression (IPC), manual lymphatic drainage, and extracorporeal shockwave therapy. Compression therapy is the most practical, effective, and cost-conscious intervention for the treatment of VLUs.[6][34] This involves the usage of various types of hosiery or bandages, which can be elastic, inelastic, single- or multi-layered.[48] Elastic materials provide moldable compression during rest and physical activity, unlike inelastic wraps.[49] According to a Cochrane review, multicomponent, stretchy systems provide superior venous ulcer healing rates compared with single-layered systems.[50] Compression strength can be light (14 to 17 mmHg), moderate (18 to 24 mmHg), high (23 to 35 mmHg), or extra-high (up to 60 mmHg). High compression is the preferred strength and should reach the knee or higher.[34] Light, cautious compression can be used in cases of mild or significant peripheral vascular disease, as indicated by the ABPI.[43] Absolute contraindications for compression therapy include arterial occlusive disease, ABPI< 0.5, serious uncontrolled high blood pressure, heart failure, suspected or documented thrombosis, extensive thrombophlebitis, erysipelas, etc.

IPC can be used in addition to compression therapy or in patients who are unable to tolerate the latter.[34] According to a systematic review, normal IPC and rapid IPC were superior to dressings and slow IPC delivery, respectively.[51] Lymphatic drainage and extracorporeal shockwave therapy have very low evidence in VLU treatment.[52][53][52]

As an adjunct to compression therapy, treatment with pentoxifylline or micronized purified flavonoids is an effective ancillary measure.[54] Both drugs have shown improved healing in various systematic reviews and meta-analyses.[55][56][57][58] There is insufficient evidence to recommend other systemic treatments, namely aspirin, zinc, doxycycline, calcium dobesilate, stanozolol, and cilostazol.[54][59]

Regarding direct ulcer interventions, these involve cleansing, debridement, infection control, application of dressings, and topical substances.[38] Cleansing should be performed with a non-toxic substance to minimize damage to the viable tissue.[34] Debridement can be achieved by surgically removing non-viable tissue, and it is strongly recommended.[49] Topical or injected anesthesia can be used to minimize discomfort. Autolytic dressings, larval therapy, and enzymatic agents are painless debridement options, albeit results may take longer.[34][38]

Although VLUs are often colonized, frank infections are less common. If infection is suspected in a new-onset painful ulcer with erythema, tenderness, warmth, and systemic signs (e.g. fever, chills), systemic antibiotic therapy should be considered. Tissue culture (as opposed to a swab) must be performed in fetid, purulent, or non-healing wounds to guide antimicrobial therapy.

Dressings maintain adequate moisture, offer physical protection, promote granulation and reepithelization. There are numerous absorptive (e. g. alginates), moisture-retaining (e. g. hydrocolloids), and antiseptic materials (e. g. silver) that can be applied to dry, exudative, and infected wounds, respectively. Topical treatments are typically used as antiseptics (e. g. cadexomer-iodine), antimicrobials (e. g. silver sulfadiazine), and debriding agents (e. g. collagenase, hydrogels).

In a Cochrane meta-analysis, sucralfate and silver dressings were the most highly ranked treatments. Interestingly, the usage of silver dressings increased the probability of healing (RR 2.43, 95% CI 1.58 to 3.74) when compared with nonadherent dressings.[60] However, this arose from low certainty evidence, and authors were unable to establish specific treatment recommendations. Since these are often more expensive materials, the benefit-cost balance must be considered.

Adjunctive therapies are recommended for non-improving ulcers after 4 to 6 weeks of standard treatment.[34] Tissue-based products may be useful for these complicated scenarios. According to a systematic review, cultured bilayered skin grafting has higher efficacy than conventional dressings when both were used in conjunction with compression therapy. There is insufficient evidence to determine if other skin substitutes can effectively improve the healing of VLUs.[61]

Invasive management intends to obliterate or remove incompetent veins through various techniques, such as sclerotherapy, open vascular surgery, radiofrequency, and endovenous procedures. These are often reserved for advanced cases when standard therapies are insufficient.[5][62] Interestingly, in a multicenter study of 450 VLU patients, those who received early endovenous ablation showed faster healing and increased time free from ulcers than those who had the procedure deferred until the ulcer was healed or after 6 months if the ulcer was unhealed.[63]

Differential Diagnosis

Other causes of lower extremity ulceration may be distinguished from VLUs based on the history and physical examination.[1] Arterial ulcers, caused by tissue ischemia, normally appear as deep, dry wounds affecting the toes, foot dorsum, and the anterior aspect of the leg, with abnormal distal pulses, ABPI, and cold extremities. Neuropathic or diabetic ulcers occur due to peripheral neuropathy and arterial disease, presenting as deep wounds, surrounded by callous, mainly over the osseous prominences of the plantar surface. Pressure ulcers arise in the setting of limited mobility, usually on the sacrum, coccyx, heels, hips, or anywhere else affected by prolonged pressure and high shear forces.

Non-vascular diagnoses should be particularly considered when ulcers show excessive granulation tissue, elevated borders, and failure to improve after standard treatment.[64] These include various types of skin cancers and pyoderma gangrenosum, for which a biopsy is essential.[65][66] Lower extremity ulceration may also occur in calciphylaxis, vasculitis, sickle-cell disease, and various other infectious and connective-tissue diseases.

Staging

There is not a specific staging instrument for VLUs, but the CEAP classification is often used in CVI patients.[39]

Clinical
C0	No visible or palpable signs of venous disease
C1	Telangiectases or reticular veins
C2	Varicose veins
C3	Edema
C4a	Pigmentation or eczema
C4b	Lipodermatosclerosis or atrophie blanche
C5	Healed venous ulcer
C6	Active venous ulcer
Etiological
Ec	Congenital
Ep	Primary
Es	Secondary (post-thrombotic)
En	No venous cause is identified.
Anatomical
As	Superficial veins
Ap	Perforator veins
Ad	Deep veins
An	No venous location was identified.
Pathophysiological
Pr	Reflux
Po	Obstruction
Pr, o	Reflux and obstruction
Pn	No venous pathophysiology identifiable

Prognosis

Based on a prognostic model, wound area and chronicity are raw determinants for healing.[67] VLUs less than 1-year-old and smaller than 10 cm^2 at the first visit had a 29% chance of closure failure by the sixth month. The probability increased to 78% for wounds older than 1 year and larger than 10 cm^2. Other reported risk factors associated with poor healing are advanced age, non-white race, high body mass index, calf muscle pump impairment, venous reflux, thrombosis, deep vein involvement, and lack of high compression.[68][69]

A multicenter study found that VLUs with a ≥ 3% increase within the first month of treatment had a 68% healing failure probability by the sixth month.[70] In another cohort, a < 30% size reduction by the first month of treatment was associated with a low probability of healing by the third month.[71] Yet, healing predictions based on area or percentage reduction remain under scrutiny.[72][73]

Healed ulcers have high recurrence rates, which considerably decrease with sustained compression therapy and vascular surgery.[6][74]

Complications

As with any chronic wound, the most common complications of VLUs include infection and pain, both of which should be controlled to improve healing outcomes and patient adherence.[36][75] Less frequently, skin cancer may develop in wounds that fail to improve over long periods of time.[65]

Deterrence and Patient Education

Individuals affected with VLUs can have an impaired quality of life, mainly related to disability.[76] Plus, heavy exudates can cause malodor, social isolation, and emotional disturbances that severely impact life quality.[76] Compliance is essential to achieve a successful outcome.[36]

Patients should be educated because VLUs are chronic processes that require lifelong evaluation and care, even after wound closure. Additionally, conformity to diet and lifestyle modifications may reduce the risk or recurrence, but evidence is lacking.[77]

Enhancing Healthcare Team Outcomes

VLUs remain an unmet clinical need. Numerous guidelines showcase that a consensus between different specialties from various countries has not been reached. Despite this, there have been some attempts at analyzing the quality and consistency of the published literature.[78][79][80] These efforts also demonstrate that an interprofessional team approach is fundamental for a thorough evaluation and treatment strategy. Primary prevention is one crucial strategy in which nurses and general practitioners should be actively participating.[81][33][82]

Patients with limb-threatening disease, severe infections, who are unable to care for themselves should be immediately admitted to the hospital for advanced management and vascular surgery consultation. Mild to moderate cases can be treated in ambulatory wound care facilities.[38] Physiotherapists should also participate in the treatment plan, as a systematic review and meta-analysis demonstrated improved healing with both aerobic and anaerobic activity [Level 2].[83]

Finally, nutrition specialists can help malnourished and overweight patients with specific guidance on how to improve their overall health, although weight management outcomes remain unclear for VLUs healing.[84][34]

(Click Image to Enlarge)

Venous leg ulcer affecting the gaiter area. The base shows considerable slough and scarce granulation tissue. The borders are irregular but well-defined. The surrounding skin shows hyperpigmentation and there is notable leg edema.
Contributed by Adriana del Carmen Rodriguez-Mena, MD

Details

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