By Gary M. White, MD
Stasis or venous ulcers are ulcers of the leg caused by chronic venous hypertension. If the skin of the leg is subject to chronic venous hypertension, breakdown and ulcer formation may occur. In one study, patients were 3.48 times more likely to be diagnosed with cancer during the 89 days after diagnosis of their leg ulcer compared with controls [Derm Times Jan 2016;p. 30].
Ulceration commonly occurs in the setting of chronic venous hypertension. The medial ankle is the preferred site. Decreased ankle range of motion is typical and may be promoted by ankle pain and swelling. The ulcer may be single or multiple, shallow and irregularly shaped. Granulation and fibrinous tissue are typical. Common accompanying features are lower extremity edema, stasis dermatitis, hemosiderin deposition and lipodermatosclerosis.
Workup should include an analysis of the arterial and venous supply system of the extremity and a vascular surgeon consulted if indicated. Both superficial and deep venous incompetence occur and sclerotherapy and/or surgery may be corrective. Some advocate screening blood work which may include: rheumatoid factor, antiphospholipid antibody, factor V Leiden mutation and antinuclear cytoplasmic antibody. The medication list should be reviewed looking for hydroxyurea and nicorandil. See above also for increased cancer risk.
The size of the ulcer should be measured at each visit. If an ulcer ever ceases to improve clinically or is present for months, a biopsy should be performed to exclude infection or malignancy (e.g., basal cell carcinoma).
As long as there is no arterial compromise, compression is critical in healing venous ulcers. This may be accomplished by a variety of methods including 4-layer dressings, Unna boot, ACE wraps, and support hose. The desired endpoint of course is prevention of edema and healing of the wound. In one study of nurse-applied compression bandages, approximately half failed to achieve optimal compression, defined as 30-50 mg Hg [JAMA Dermatol 2014 May 14]. Better training and measurement evaluation is in order.
Some recommend strengthening the calf muscles to reduce edema. The may be done with standing heel rises (e.g. 20-30) performed several times a day or full-stride walking or stair climbing. Leg compression helps decrease pain and increase ankle range of motion [JAMA Derm 2016;152;472]. This facilitates calf muscle pump function, decreased swelling and increased healing.
A variety of wound care dressings are available and the help of a wound care specialist can be invaluable. In general, a moist, clean, uninfected wound without surrounding edema has the best chance to heal. Debridement is often needed to remove dead tissue, slough, and fibrinous plaques. Pain, however, may be extreme. Pretreatment with analgesics and the usage of EMLA cream (thick layer of cream applied to the ulcer and covered with plastic wrap, e.g., Saran Wrap, for 30-45 minutes before) is very helpful at reducing the pain [JAAD 1999;40;208]. An oral antibiotic should be given for infected wounds, but it should be remembered that colonization of the wound by bacteria should be expected. Fungal superinfection may occur as well. If there is suspicion, a KOH preparation or culture should be performed. Contact allergy is a potential complicating factor. Therefore only those topical agents essential to healing should be used.
If exuberant granulation tissue develops, a silver nitrate stick may be applied to the area periodically.
A vascular surgeon should be involved in the care of the patient and surgical intention performed if indicated, e.g., to perforantectomy in the setting of insufficient perforators.
A split-thickness skin graft (STSG) can sometimes accelerate healing.
A meta analysis of randomized trials found that Pentoxifylline was more effective than placebo in treating venous ulcers. Start low and aim for 800 mg TID.
Topical timolol, 1 drop every 2 cm along the wound edge, allowed to dry for 2 minutes, reduced wound size after 7 weeks of treatment by 78% in 5 patients [JAMA Derm Dec 2013;1400]. The diagnosis in these patients was venous ulcer in 2, pressure ulcer, traumatic wound and one of mixed venous and sickle cell.
Simvastatin 40 mg/day in addition to standard wound care and compression, significantly speeded healing time for venous ulcers [BJD 2014:170:1151].
Spray-applied cell therapy using human allogeneic fibroblasts and keratinocytes has improved chronic leg ulcers [Wound Repair Regen 2013;21:682-7].
Fractional carbon dioxide laser treatment appeared to accelerate healing in post-traumatic wounds on the lower extremities of elderly patients [JAMA Derm 2015;151;868].
In one study [AD 1999;135;920], the prognosis for healing was poorer for larger ulcers, or if there was a history of venous ligation or stripping, hip or knee replacement surgery, ankle brachial index of less than 0.8 and the presence of fibrin on more than 50% of the wound surface.
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