Venous and arterial leg ulcers
A leg ulcer occurs when skin breaks down, usually on the lower leg area, just above the ankle. Leg ulcers affect about 1 in 1000 people in Europe and are more frequent in elderly people: about 20 out of 1000 people are affected by the time they reach their eighties.
The majority of leg ulcers, about 80%, are caused by venous disease (venous leg ulcers), about 20% are of arterial (arterial leg ulcers) or mixed origin. If not treated correctly, a leg ulcer can become a chronic wound which requires longer healing time (sometimes more than 6 months), and they have a tendency to reoccur.
What is a venous leg ulcer?
The cause of venous leg ulcers is venous insufficiency due to damage in the valves in the larger veins. Venous leg ulcers can be painless, but some are very painful. They can become infected. There is often an inflammation (dermatitis) around the venous leg ulcer.
Competent and well functioning valves are necessary for:
- Fractionating blood flow
- Ensuring one-way circulation
- Low blood pressure
When you valves are damaged:
- Blood accumulates in the lower legs
- High blood pressure
This means that the veins or blood vessels by which the blood returns to the heart, are not functioning efficiently, which results in accumulation of the blood in peripheral blood vessels and increased pressure in lower leg veins. The consequence is fluid leackage from the veins beneath the skin. This results in swelling, thickening and damage to the skin. The damaged fragile skin may break down and form an ulcer.
Risk factors:
People most at risk of developing venous leg ulcers are those who have previously had have a leg ulcer. Other risk factors are:
- Varicose veins
- Previous deep vein thrombosis in the affected leg
- Phlebitis in the affected leg
- Previous fracture, trauma, or surgery
- Family history of venous disease
- Symptoms of venous insufficiency: leg pain, heavy legs, aching, itching, swelling, skin breakdown, pigmentation and eczema
Prevention:
If you are at risk of developing venous leg ulcers, a few simple measures can help reduce the risk of developing a venous leg ulcer in several ways, such as wearing a compression stocking, losing weight and taking care of your skin.
Compression stockings:
If the patient is at risk of developing venous leg ulcers, or you have previously had a venous leg ulcer, your GP will probably prescribe compression stockings. These stockings are specially designed to steadily squeeze your legs, which improves your circulation. They are usually tightest at the ankle and get gradually looser as they go further up your leg, ensuring blood flow upwards towards your heart. To be most effective, these stockings need to be worn at all times when you are out of bed. A nurse can help you to find compression stockings that fit correctly and that you can manage yourself. There are various accessories you can buy to help get the stockings on and off.
Losing weight:
If you are overweight, losing weight can help prevent venous leg ulcers. Excess weight contributes to increased pressure in the veins in your legs, which can damage your skin. Venous ulcers are much more common among people who are obese than in people of normal weight. The combination of a balanced diet and regular moderate physical activity will help you lose weight. Walking as often as possible is an excellent exercise. Avoid long periods of sitting or standing and elevate your legs whenever possible.
Treating underlying problems:
Venous disease manifests as varicose veins, one of the main causes of venous leg ulcers. They can be treated with various methods, all designed to remove the damage veins. A specialist will advise the method: varicose veins can be treated using laser, by injecting the products which will close the affected veins, or by using a procedure where a catheter (a thin, flexible tube) is inserted into the affected veins, and high-frequency radio waves or lasers are used to seal them. Alternatively, you may need surgery to repair the damage to your leg veins or to remove the affected veins altogether.
Venous leg ulcers treatment:
If you have a venous leg ulcer, a home care nurse will apply the wound management procedures with custom cleansing products and wounds dressings. It is very important that you and your family are informed that the treatment will only be successful if the compression bandages are worn as advised by a nurse. This may be a perceived as a constraint, but the healing rates are considerably improved if the compression is maintained. Elevating legs and other preventive measures are very important to achieve rapid wound closure and to avoid re-occurrence of venous leg ulcers.
What is an arterial ulcer?
Arterial leg ulcers are caused by insufficient arterial blood flow to the lower extremities. The direct cause of reduced blood flow is vessel wall arteriosclerosis and atherosclerotic plaque accumulation causing vessel occlusion. Peripheral vascular disease associated with arterial insufficiency may result in limb tissue ischemia. In case this condition is prolonged, the skin on the leg becomes thin with loss of hair, subcutaneous tissue and muscles atrophy, nails become thickened, leg color and temperature change becoming pale and cool, pulses become difficult to palpate and pain increases with exercise or leg elevation.
The treatment of arterial leg ulcers requires a multidisciplinary approach. It is necessary to ensure a proper blood flow, which often involves surgical intervention. The patient must be encouraged to adopt and maintain healthy lifestyle changes which will help to improve tissue perfusion.
Risk factors:
- Coronary heart disease
- History of stroke or transient ischemic attack
- Diabetes mellitus
- Peripheral arterial disease including intermittent claudication
- Obesity and immobility
Prevention:
The lifestyle changes that you can adopt will contribute to improve peripheral circulation and help prevent arterial leg ulcers, if you are at risk.
Stop smoking:
Smoking severely reduces the tissue perfusion and is one of aggravating factors for arterial leg ulcers. You are advised to stop smoking to prevent the occurrence of arterial ulcer if you are at risk, especially if you already have an arterial ulcer.
Healthy diet and weight loss:
It Is important to reduce the intake of fat and to keep your cholesterol levels low. You should exercise as much as possible: this will help improve the blood circulation in your legs. If during exercising you feel some pain in your legs, it is normal. If the pain is more pronounced, or severe, it may be a sign that your arteries are seriously narrowed due to atherosclerosis. This needs to be addressed by a doctor.
Take good care of your feet:
- Wear shoes which fit correctly and are not too small.
- Keep your feet warm and try to avoid feet and legs injuries.
- Examine your feet and legs daily for any changes in color or developing sores.
- Moisturize the skin well to prevent skin damage which can develop into ulcers.