What are venous ulcers?
Wounds that are thought to occur due to improper functioning of venous valves, usually of the legs
What causes venous ulcers?
The exact cause is uncertain, but they are thought to arise when venous valves that exist to prevent backflow of blood do not function properly
How does the failure of functioning of venous valves cause venous ulcers?
The incompetent valves cause blood to be squeezed out into the superficial veins when the calf muscles are contracted, instead of upwards towards the heart. Dilation of superficial veins occurs, and the subsequent raised venous pressure results in oedema, venous eczema, and ulceration
What are the risk factors for venous ulcers?
- Deep vein thrombosis
- Pre-existing venous incompetence, including varicose veins
- Trauma
- Pregnancy
- Obesity
What do venous ulcers look like?
Venous ulcers are usually large, shallow, and situated around the medial or lateral malleoli.
Are venous ulcers painful?
Yes, particularly worse at the end of the day
What other signs are venous ulcers associated with?
Other signs of venous insufficiency, such as;
- Varicose veins
- Varicose eczema
- Oedema
- Lipodermatosclerosis
- Atrophie blance
- Haemosiderin pigmentation
What history features suggest venous ulceration?
- Pre-existing varicose veins
- Deep vein thrombosis
- Phlebitis
- Previous fracture, trauma, or surgery
- Family history of venous disease
- Symptoms of venous insufficiency
What symptoms of venous insufficiency might be reported in the history?
- Pain or heaviness in the legs
- Aching
- Itching
- Swelling
What features in the history suggest a non-venous cause of ulcers?
- FHx of non-venous ulcers
- History of heart disease, stroke, TIA
- Diabetes mellitus
- PVD or intermittent claudication
- Cigarette smoking
- RA
How is a diagnosis of venous ulcer made?
The diagnosis is clinical, with the underlying venous insufficiency confirmed by a Duplex ultrasound
Why is ABPI sometimes required in the diagnosis of venous ulcers?
To exclude arterial disease before the application of compression bandaging
What features of the ulcer might cause you to suspect infection?
- Erythema
- Purulent exudate
What should be done if infection of a venous ulcer is suspected?
Consider microbiology swabs and antibotic sensitivites
How are venous ulcers managed?
- Graduated compression
- Debridement, cleaning, and dressing
- Antibiotics in infected ulcers
- Pentoxifylline
What should be done before graduated compression treatment for venous ulcers is tried?
- Diabetes, neuropathy, and PVD should be excluded
- Pre-existing swelling should be controlled by bed rest or elevation
What does graduated copmression treatment involve?
Applying bandages to the leg, maximising the pressure at the ankle and gaiter area, and reducing the pressure as you go higher up the leg
What is the purpose of graduated compression treatment for venous ulcers?
It helps control or reverse the venous insufficiency
What is pentoxifylline recommended in?
The treatment of chronic venous ulcers
How long after a venous ulcer should pentoxifylline be given for?
6 months
How does pentoxifylline help in venous ulcers?
it is thought to improve the microvascular circulation
When is a venous ulcer deemed chronic?
If it fails to respond to first-line treatment after 4 weeks
What is involved in the primary prevention of venous ulcers?
- Avoidance of prolonged standing or sitting
- Control of risk factors
- Use of compression hosiery when there are early signs of venous insufficiency
What is involved in the secondary prevention of venous ulcers?
- Correctly fitted compression hosiery should be worn for 5 years after an ulcer
- Underlying co-morbidities should be managed
- Vascular surgery can be considered in certain cases
