Leg
ulcers
The most common cause of leg ulceration in Western countries is venous
disease of the lower limb. However, many patients have other causes for
their leg ulcer. The most frequent associated cause is peripheral arterial
disease, which may be the sole cause for ulceration or may occur with venous
disease. Because of this common association with arterial disease, patients
presenting with leg ulceration should be investigated for arterial disease as
well as for vein problems. In addition, a number of other common conditions
may cause leg ulceration. A brief list of the causes of leg ulcers is given in
Table 16.1.
Examination
and investigation
Clinical examination should be performed carefully. The ulcer itself
should be examined to establish its location.
In
patients suspected of suffering lower limb venous or arterial disease as the
cause of the ulceration, complete examination of the venous system by duplex
ultrasonography combined with measurement of Doppler ankle blood pressures is
the most appropriate investigation in the first
Management
of venous leg ulcers
In patients who have venous ulceration due to superficial venous
incompetence alone, varicose vein surgery is effective in producing ulcer
healing in those patients who are fit enough to undergo this treatment. In the
authors’ experience it is not necessary to delay surgery until the ulcer has
healed. The ulcer is covered by a dressing during surgery and prophylactic
antibiotics are given to prevent infection of the surgical wounds with any
bacteria present in the ulcer. Ulcers managed in this way usually heal rapidly
(within 4 weeks) following surgery.
In
those patients with deep venous insufficiency or who are unfit or unwilling to
undergo surgery, standard ulcer management should be used. The mainstay of this
is local ulcer management combined with the application of compression. The
ulcer is cleaned by soaking in tap water (the use of sterile water is
unnecessary) and debriding the ulcer to remove any slough. The skin of the leg
often becomes very scaly beneath compression dressings and should be treated
with emulsifying ointment. No topical application has been shown to speed the
healing of a venous leg ulcer, and patients with venous disease of the lower
limb are very likely to become allergic to dressing materials. Topical
antibiotics are ineffective in healing leg ulcers and are particularly likely to
produce skin sensitisation. They should never be used in the management
of venous ulceration. Patients who have eczematous reactions around their ulcers
may require the use of topical steroids to treat the allergic response. The
dressing material should follow standard guidelines — see Chapter 3 on
‘Wounds, tissue repair and scars
The
most important factor in achieving healing is the use of high levels of
compression. The use of dressings alone leads to a very slow rate of ulcer
healing. It has been found that pressures of 3 0—45 mmHg applied to the ulcer
are much more effective than lower levels of compression. These can be achieved
by the use of compression stockings or by bandaging. Class 3 stockings exert
about 30 mmHg compression at the ankle but require the patient to have
sufficient strength in their hands to apply these. They are useful in younger
patients who wish to manage their own ulcer. Frail patients often cannot manage
this type of stocking, but may be able to apply two stockings of lower
compression to the limb or use a stocking with a zip fastener in the seam. The compression
need only be applied to the ulcer region, so patients with venous leg ulcers
should wear below the knee
Drug
treatment for leg ulcers
No drugs have been found which are more effective than compression
bandaging in the management of venous leg ulceration. Antibiotics have no effect
on ulcer healing but are required if infection develops around an ulcer. This
usually takes the form of cellulitis but, surprisingly, only occurs
occasionally.
A few drugs have been investigated to assess their efficacy in venous ulcer
healing. These have included aspirin, oxpentifylline (Trental, Hoechst),
prostaglandin El analogue and diosmin (Daflon 500 mg, Servier). All of these
have an effect on leg ulcer healing but none is currently in widespread use.
Future developments in understanding of the pathology of leg ulcers may lead to
improvements in drug treatment for this condition.