Essential Insights On Treating Chronic Venous Stasis Ulcers

Nanjin J. Park, DPM, Latricia Allen, DPM, MPH, Guosheng Gu, MD, and Vickie R. Driver, DPM, MS, FACFAS

   The base of a venous ulcer is usually red and may be covered with yellow fibrous tissue. If the venous ulcer is infected, there may be a green or yellow discharge. The drainage amount can vary from minimal to moderate. The borders of a venous ulcer are usually irregularly shaped and the surrounding skin is often discolored and swollen. The ulcer may even feel warm or hot. The skin may appear shiny and tight, depending on the amount of edema. The skin may also have brown or purple discoloration, known as “stasis skin changes,” about the lower leg.

   Venous stasis ulcers are common in patients who have a history of leg swelling, longstanding varicose veins or a history of blood clots in either the superficial or the deep veins of the legs. Ulcers may affect one or both legs.

   The differential diagnosis for the venous stasis ulcer can include ischemic ulceration, pyoderma gangrenosum, lymphedema, trauma, neuropathic ulceration and cellulitis (see “What Are The Differential Diagnoses For Venous Leg Ulcers?” at right).10 Complete assessment of the patient’s medical history is critical as treating the wrong etiology is a common reason for prolonged ulcerations with a poor outcome. When it comes to patients with suspected venous ulcerations, one should ensure a thorough clinical history, physical examination, appropriate laboratory tests and a hemodynamic assessment. Doing so will enable one to identify both the underlying cause and any associated diseases, and influence decisions about prognosis, referral, investigation and management.

   Also keep in mind that if the ulcer persists beyond 12 weeks despite the best evidence-based treatment efforts, one must take a biopsy to rule out carcinogenic conversion or any suspected differential diagnoses.

   The venous duplex test is helpful in assessing the superficial and deep venous system of the lower extremity to determine the presence or absence of deep or superficial vein thrombosis. We commonly use the venous duplex test to diagnose chronic venous insufficiency. However, the venous reflux test is more specific than the duplex test since this will show the dysfunctional valve system. Additional diagnostic tools for chronic venous insufficiency include computed tomography (CT), which is not very cost effective. It is important to order ankle brachial indices (ABI) not for diagnostic purposes but rather to determine safe levels of compression therapy. However, the gold standard for diagnosing chronic venous insufficiency is venography. We highly recommend consulting a vascular surgeon early in the treatment process.

Essential Insights On Treatment

The most important goal for the treatment of venous leg ulcers is long-term edema control. The revised validated venous stasis ulcer guideline by AAWC recommends delivery of evidence-based care by qualified professionals using a multidisciplinary team for effective venous ulcer treatment.1 Therefore, it is paramount to get a thorough history, physical examination, and consult the proper team members for development of a collaborative treatment strategy. We believe it is important to consult vascular surgery at the beginning stages of treatment.

   Treatment depends on the aforementioned CEAP classification. For patients in Categories 1-4, we emphasize conservative treatment with bed rest, leg elevation and compression stockings.

   In addition, one may consider treatments provided by vascular surgeons. These treatments include: injecting a sclerosing agent directly into veins; superficial and perforating vein ablation; deep vein reconstruction; and subfascial endoscopic perforator vein surgery combined with superficial vein ligation. If an ulcer is present, we recommend the aforementioned conservative treatments and adding local wound care to keep the wound site clean and non-infected. Therefore, cleansing the wound with each dressing change is important.

   Clinicians can determine the appropriate type of dressing for ulcers by the appearance of tissue type on the ulcer base (see “How To Select The Optimal Dressing For Venous Ulcers” at left).11

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