Chronic leg ulcers

Chronic leg ulcers-defn.

• full thickness skin loss present for more than 4

weeks

slow healing tendency caused by an underlying pathogenetic factor that

needs to be removed to induce healing.
 Impact of chronic leg ulcers
• every aspect of a person’s daily life:

– pain
– impaired sleep
– restricted mobility and work capacity,
– strain on personal finances,
– restricted social activities due to fear of injury and negative body image.

• Financial burden on the health system(UK, venous leg ulceration alone

has been estimated to cost the NHS £400m a year).
 Prevalence

• 1% in the adult population

• 3–5% in the population over 65 years of age

• Two peak periods in the age of presentation(30-39 and 50-69 years).

Ryan TJ. The epidemiology of leg ulcers. In. Leg Ulcers: Diagnosis and Treatment (Westerhof W, ed.). Amsterdam: Elsevier SciencePublishers
BV, 1993: 19–27.
GA Rahman1, IA Adigun, A Fadeyi,
Annals of African Medicine:2010,Vol.9; 1,pp: 1-4      Epidemiology, etiology, and treatment of chronic leg ulcer: Experience with sixty patients
 Etiology
• Venous disease (50-75%) • Malignancy

• Peripheral arterial disease

• Infections
• Mixed venous/arterial
• Radiation
• Connective tissue diseases

• Neuropathy
• Diabetes mellitus

• Sickle cell disease • trauma

 African situation
• Trauma - 56.7%

• Infection - 31.7%

• vascular causes -3.3%

• malignancy 3.3%

• Sickle cell disease(can be up to 40% in endemic areas)

GA Rahman1, IA Adigun, A Fadeyi,

Annals of African Medicine:2010,Vol.9; 1,pp: 1-4      Epidemiology, etiology, and treatment of chronic leg ulcer: Experience with sixty patients
 Diagnosis

• thorough history and physical examination

– comprehensive assessment of
• the patient,
• skin,
• vascular status,
• limb and
• ulcer
Venous ulcer
Arterial ulcer
Diabetic foot
 Investigations

• Hemogram

• LFT

• U/E

• Doppler ultrasound

• venography

• Wound swabs-controversial

• Wound biopsy - if in 8-12 weeks the ulcer has not healed

 Management

• Supportive
– Correct anemia
– Correct nutritional deficiencies
– Good metabolic control in diabetes mellitus

• underlying causes should be addressed

• Wound care
– Debridement
– Dressings- should maintain a warm moist environment
– Skin grafting
– Flap cover
 Venous ulcer
• Most common in the Western population

• Affects the area above the malleoli

• If circumferential-’Champagne bottle
appearance’

• Common in females and obese people

 Pathophysiology of venous ulcers
• Venous hypertension in both the superficial and deep venous systems

• Pericapillary fibrin cuff formation,

• chronic reperfusion injury

• Trapping and activation of white blood cells and growth factors

 Clinical features
• aching,
• heaviness of the legs,
• itching,
• lipodermatosclerosis,
• pigmentation,
• swelling,
• eczema, and
• ultimately ulceration
 Diagnosis
• Clinical
– History of varicose veins, DVT
– Ulcer
– Varicose veins

• Investigations
– Doppler ultrasound
– Ascending phlebography
Venous ulcer
 Management

• Conservative
– Leg elevation

– Multilayered, graduated ,elastic compression stocking - 40mmHg pressure at the ankle

(Heals 60-75% of the ulcers in 3-4 months)

arterial insufficiency should be ruled out before applying a compression bandage

– Improve nutrition

• Surgery in selected cases

 Recurrence

• 26% at one year and 31% at 18 months for

the compression method

• 9% at three years in case of superficial venous

surgery