What are venous leg ulcers

What are venous leg ulcers

A venous leg ulcer is one of the most common types of wound in the leg. These tend to persist and donot heal until the underlying venous disease is managed by one way or the other.

This ulcer discolours the affected area and the skin around the ulcer becomes hardened. The open lesion may also produce a discharge with foul smell.

People over the age of 65, have more chances of developing venous leg ulcer.

If venous leg ulcers are left untreated, it can develop into more severe issues.

The most common reason for venous ulcers is untreated varicose veins. They may develop because of excessive itching / minor trauma / minor burn (eg with silencer of a two wheeler). The other reason is obstruction or narrowing of superficial veins because of compression by other structures in the body / because of old deep vein thrombosis (May Thurner Syndrome, Post thrombotic syndrome)

Symptoms of venous leg ulcers

Symptoms of leg ulcers may vary according to the exact cause of the ulcer.

Here are the symptoms:

  • Open wound
  • Pain in the affected area
  • Itchiness around the sore
  • Burning sensation
  • Developing rash or dry skin
  • Increasing the size of the sore
  • Swelling leg
  • Swollen ankles (edema)
  • Enlarged veins
  • Heaviness in the leg
  • Discolouration and darkening around the lesion
  • Aching
  • Restless leg
  • Oozing foul-smelling liquid discharge from the sore.

If the ulcer is treated early with correction of venous disease and local management of the ulcer, it will improve without any further complications. 

Causes of venous leg ulcers

The most important and the basic cause of all venous ulcers is venous hypertension. Normally, there are valves in the veins which allow only one way flow of the blood i.e. from legs towards the heart. However, when these valves start malfunctioning, blood starts collecting in the legs and results in increased pressure of the whole blood column in the leg veins. This results in reduced healing capacity of the leg and leads to a non healing ulcer

Causes of venous leg ulcers

As you may have heard, people with diabetes have a significantly reduced healing capacity. Diabetic patients have an extra causative factor for non healing ulcers if they also have a concurrent venous disease.

Is venous leg ulcer hereditary?

It’s a misconception that leg ulcer is hereditary. It is not a hereditary disease. The reasons that may enhance the risk of developing venous leg ulcers that can be genetic.

The reasons are-

  • Poor valves
  • The tendency of developing a blood clot
  • Twisted or abnormal veins

What does a venous ulcer looks like?

A venous ulcer looks like a bumpy large open, and the deep moist wound may be covered in a yellowish or greyish layer. Often, the foul-smelling liquid discharge comes out of the ulcers. These ulcers are usually superficial and may be multiple.

Who is at risk?

Venous leg ulcers are common in both men and women. It is more common in older people.

Risk factors for venous leg ulcers

  • Varicose veins
  • Older age
  • Family history of venous insufficiency or blood clots (DVT).
  • Obesity
  • Diabetes
  • Surgery
  • Trauma
  • Any leg fracture
  • Minor or major injures
  • Pregnancy
  • Sitting or standing for an extended period
  • Osteoarthritis.

Treatment for venous leg ulcer

Venous leg ulcers can be treated if proper treatment is initiated. Even long standing ulcers like those which are there since upto 20 years have been treated.

There are two arms of the treatment which have to go side by side. First arm is management of Venous disease by compression / venous interventions to remove the underlying cause. The second arm consists of Venous leg ulcers consists of local treatment of the leg ulcers with dressings.

Treatment options depend on the chronicity and severity of the leg ulcer. 

Here are the treatment options:

  • Managing venous disease
    • Compression therapy – multilayered dressing / class 3 stockings
    • Varicose veins treatment – EVLT / RFA / Glue / MOCA / phlebectomy
    • Sclerotherapy for perforators / spider veins
    • Treatment of deep vein diseases – Venoplasty, Venous stenting
  • Treatment of ulcer at local site
    • Various dressings with hydrogels / silver coated
    • Debridement of infected tissue
    • Skin grafting

Compression therapy

In this therapy, compression bandages or stockings are used to treat venous leg ulcers. They are specially designed to put sequential pressure (high pressure at ankle and a bit lower as we move up the leg) and squeeze the leg.

Compression bandage puts constant pressure on the legs externally which helps in flow of blood through the veins back to heart. This reduces the venous blood pooling and therefore venous hypertension is decreased.

          EVLT / RFA / Glue / MOCA / Phlebectomy

Varicose veins can be treated by EVLT (Endovenous laser treatment) / RFA (Radiofrequency ablation) / Glue / MOCA (mechanicochemical ablation) / phlebectomies (surgery). These treatments are very successful and can really help a great deal in treating venous leg ulcers. The basic reason for this is that these procedures ablate the superficial veins that had faulty valves. Therefore, blood pooling in legs is eliminated and venous hypertension goes down.

          Sclerotherapy

Sclerotherapy can be used to treat major superficial veins as well as spider veins. These both can be significant contributors towards causing venous hypertension in the legs.

          Venogram and Venoplasty +/- Stenting

Deep vein disease of the leg is often ignored and even some health care professionals are unaware of this problem. This disease can be easily treated by opening up of the diseased veins with balloon angioplasty and / or stenting and thus, provide a more streamlined flow of blood from legs to the heart and reducing venous hypertension in the leg.

Cleaning and dressing the ulcers

It is essential to clean any wound properly so that the wound won’t progress further. Similarly, the first step is to clean and remove the dead tissues over the ulcer and then apply proper clean and dry dressing on the ulcer.  Dressing may be hydrogel dressing if the wound is very dry and also, it may be silver coated if the physician deems it to be a bit infected.

Debridement surgery

In this surgery, the surgeon removes the infected tissue or dead tissue to enhance healing.

There are various methods of debridement. These are-

  1. Surgical debridement
  2. Mechanical debridement
  3. Enzymatic debridement
  4. Autolytic debridement
  5. Biosurgical debridement.

Skin grafting

Once the underlying venous disease is treated, skin grafting can be done over a healthy ulcer so that the patient’s ulcer is treated early and he is free from regular dressings.

Preventions to avoid venous leg ulcers?

Venous leg ulcers can be prevented by changing the lifestyle and following the precautions.

  • Control high blood pressure and diabetes
  • Exercise regularly
  • Keeps leg elevated during night especially if you have a venous disease
  • Avoid sitting and standing for too long (If you can’t avoid it, then frequently move your leg when possible)
  • Maintain weight
  • Avoid smoking and alcohol consumption
  • Be careful don’t hurt your leg
  • Wear compression bandages or stockings
  • Daily walk for at least 20-40 minutes

If you notice any signs of hyperpigmentation / ulceration / bleeding spot in your leg, then it is best to consult a vascular surgeon as quickly as possible before the ulcers develop into serious issues.

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