Current Concepts In Diagnosing Chronic Diabetic Foot Ulcerations

Start Page: 60

What About Chronic Venous Stasis Ulcerations?

When patients report their history in a particular way, one can suspect chronic venous stasis ulceration. Often, this description will include discomfort that patients report as a deep aching sensation within their legs.

• “I had to stop wearing my compression stockings because they were making my legs swell.”
• “I just began noticing drainage on my stockings.”
• “I noticed water blisters on my legs but did not know what to do about them. Now I have sores on my legs that just will not heal.”

Fluid retention within the legs, ankles or feet is a hallmark of this condition. The pathomechanics for venous ulcer development includes inflammation that stimulates leukocyte activation, endothelial damage, platelet aggregation and intracellular edema. That sounds an awful lot like the mechanism for blood clot formation. Among the risk factors for venous ulcer development are older age, obesity, previous leg injuries, deep venous thrombosis and phlebitis.

In this instance, the chronic condition is venous stasis, not necessarily the ulceration. Often occurring on the medial ankle and associated with chronic pain, venous stasis ulcerations require therapy to address the wound as well as mechanisms to address fluid retention in the limb to reverse the process successfully. At times, the medical team employs medications to encourage diuresis when appropriate.

The use of compression hose is the mainstay in long-term management of venous stasis ulcers. Often, these modalities range from 20 mmHg compression to 30 mmHg compression. While elevation, the use of compression hose and local wound care can be effective, the risk and rate of recurrent ulceration is a reality. Researchers have demonstrated that surgical correction of superficial venous reflux reduces 12-month ulcer recurrence.46 In that study, the authors concluded that most patients with chronic venous stasis ulcerations will benefit from simple venous surgery. This conclusion was evident in the fact that 12-month ulcer recurrence rates were significantly reduced in the compression hose and surgery group in comparison to compression therapy alone (12 versus 28 percent).

With this in mind, I cannot overstate the importance of getting a vascular surgery consultation in the case of chronic venous stasis complicated by ulceration. Considering the data that 1 to 2 percent of the population will suffer from chronic venous ulceration, delayed healing times and increased incidence of recurrence are predictable.47,48 Recurrence rates are reportedly as high as 26 to 28 percent and one study reported a 68 percent recurrence rate.46,48-51 As many as 10 percent of the U.S. population may suffer from valvular incompetence in the venous system and 0.2 percent of those patients may develop an ulceration.52 It is understood that recurrent ulceration may occur in as many as 70 percent of those at risk.52

  • « Previous
  •  | Page 1 of 2 | 
  • Next »
71
Author(s): 
Molly Judge, DPM, FACFAS

28. Sibbald RG, Schachter RK. The skin and diabetes mellitus. Int J Dermatol. 1984; 23(9):567-84.
29. Boulton AJM, Cutfield RG, Abouganem D, et al. Necrobiosis lipoidica diabeticorum: A clinicopathologic study. J Am Acad Dermatol. 1988;18(3):530-7.
30. Meurer M, Szeimies RM. Diabetes mellitus and skin diseases. Curr Probl. 1991;20:11-23.
31. Braverman IM. Skin Signs of Systemic Disease. WB Saunders, Philadelphia, 1981, pp. 654-64.
32. Huntley AC. The cutaneous manifestations of diabetes mellitus. J Am Acad Dermatol. 1982;7(4):427-55.
33. Eaton PR. The collagen hydration hypothesis: A new paradigm for the secondary complications of diabetes mellitus. J Chron Dis. 1986;39(10):753-66.
34. Buckingham BA, Uitto J, Sandborg C, et al. Scleroderma-like changes in insulin dependent diabetes mellitus: Clinical and biochemical studies. Diabetes Care. 1984;7(2):163-9.
35. Lieberman LS, Rosenblum AL, Riley WJ, et al. Reduced skin thickness with pump administration of insulin. N Eng J Med. 1980;303(16):940-1.
36. Brem H, Sheehan P, Boulton AJM. Protocol for treatment of diabetic foot ulcers. Am J Surg. 2004; 187(Suppl):1S–10S.
37. Boulton AJ. The diabetic foot: a global view. Diabetes Metab Res Rev. 2000;16(suppl 1):S2–S5.
38. Centers for Disease Control and Prevention (CDC). History of foot ulcer among persons with diabetes—United States, 2000–2002. MMWR Morb Mortal Wkly Rep. 2003;52(45):1098–1102.
39. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and 
amputations in diabetes. In: Harris MI, Cowie C, Stern MP, (ed.) National Diabetes Data Group of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Md. 1995, pp. 409–428. NIH Publication No. 95-1468.
40. Bowering CK. Diabetic foot ulcers: pathophysiology, assessment, and therapy. Can Fam Physician. 2001;47:1007–1016.
41. Frykberg RG, Armstrong DG, Giurini J, et al. Diabetic foot disorders: a clinical practice guideline. J Foot Ankle Surg. 2000;39(suppl):S1–S60.
42. Boulton AJ, Meneses P, Ennis WJ. Diabetic foot ulcers: a framework for prevention and care. Wound Repair Regen. 1999;7(1):7–16.
43. Apelqvist J, Bakker K, van Houtum WH, Nabuurs-Franssen MH, Schaper NC, for the International Working Group on the Diabetic Foot. International consensus and practical guidelines on the management and the prevention of the diabetic foot. Diabetes Metab Res Rev. 2000;16(suppl 1):S84 –S92.
44. Brem H, Jacobs T, Vileikyte L, et al. Wound-healing protocols for diabetic foot and pressure ulcers. Surg Technol Int. 2003;11:85–92.
52. Sheehan P, Jones P, Caselli A, et al. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care. 2003; 26(6):1879-1882.
46. Barwell JR, Davies CE, Deacon J, et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet. 2004;363(9424):1854-9.
47. Moffatt CJ, Franks PJ, Oldroyd M, et al. Community clinics for leg ulcers and impact on healing. BMJ. 1992; 305(6866):1389–92.
48. Ghauri ASK, Taylor MC, Deacon JE, et al. Influence of a specialized leg ulcer service on management and outcome. Br J Surg. 2000; 87(8):1048–56.
49. Barwell JR, Taylor M, Deacon J, et al. Surgical correction of isolated superficial venous reflux reduces long-term recurrence rate in chronic venous leg ulcers. Eur J Vasc Endovasc Surg. 2000; 20(4):363–68.
50. Franks P, Oldroyd M, Dickson D, Sharp E, Moffatt C. Risk factors for leg ulcer recurrence: a randomised trial of two types of compression stocking. Age Ageing. 1995; 24(6):440–94.
51. Monk BE, Sarkany I. Outcome of treatment of venous stasis ulcers. Clin Exp Dermatol. 1982; 7(4):397–400.
52. Gohel MS, Barwell JR, Earnshaw JJ, et al. Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR study)—haemodynamic and anatomical changes. Br J Surg. 2005;92(3):291-7.

image description image description


Post new comment

  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.

More information about formatting options

Image CAPTCHA
Enter the characters shown in the image.