Venous ulcers

Question 1

Definition

Answer 1

• Most common type of leg ulcer
• Caused venous incompetence and associated venous hypertension (pooling of blood and waste products in the skin secondary to venous insufficiency)

Question 2

Risk factors

Answer 2

• Varicose veins
• DVT
• Chronic venous insufficiency
• Poor calf muscle function
• Arterio-venous fistulae
• Obesity
• History of leg fracture
• Immobility
• Previous ulcer
• Personal or family history of varicose veins
• Personal history of DVT
• Prolonged standing

Question 3

Symptoms

Answer 3

Pain
Heaviness
Aching
Swelling
Itching (worse at the end of the day and relieved by leg elevation)

Question 4

Signs

Answer 4

• Lipodermatosclerosis = long-term venous insufficiency where there is thickening and fibrosis of adipose tissue under the skin causing atrophic changes:
• Loss of sweat glands
• Hair follicles
• Pigmentation changes
  And can cause tapering of the legs (inverted champagne bottle)
• Venous eczema; erythema, scaling, weeping, and itching
• Haemosiderin staining

Question 5

Diagnosis

Answer 5

Doppler for ABPI
Bloods
- FBC (anaemia and WCC for infection)
- ESR and CRP (inflammation and infection)
- Urea and creatinine (high urea and may indicate dehydration which impairs healing)
- Albumin (low albumin associated with protein loss and malnutrition delaying healing), HbA1c
- Bacterial swabbing (infection), Skin biopsy (atypical ulcers and clinical suspicion for skin cancer)

Question 6

Management

Answer 6

Nursing care
- Regular dressing changes
- Debridement (removal or slough) + necrotic tissue
- Keep moist
- Avoid antiseptics (toxic to cells and slow healing)
- Cleaning (with saline)

Pharmacological management
- Pentoxifylline (improves healing but is not licences)
- Abx
- Avoid NSAIDs and smoking cessation
- Emollients for varicose eczema

Compression
Elevation (above the heart to aid venous drainage)
Encourage exercise (improve pump action of calf muscle which aids with venous return)
Severe cases may require surgery.