The venous ulcer continues to be a clinical challenge: an update

Abstract

Venous ulcers are a common chronic problem in many countries especially in Northern Europe and USA. The overall prevalence of this condition is 1% rising to 3% in the over 65 years of age. Over the last 25 years, there have been many developments applicable to its diagnosis and treatment. These advances, notwithstanding healing response and recurrence, are variable, and the venous ulcer continues to be a clinical challenge. The pathogenesis of venous ulcers is unrelieved or ambulatory venous hypertension resulting mostly from deep venous thrombosis leading to venous incompetence, lipodermatosclerosis, leucocyte plugging of the capillaries, tissue hypoxia and microvascular dysfunction. It is not known what initiates venous ulcers. Triggers vary from trauma of the lower extremity to scratching to relieve itchy skin over the ankle region. Venous ulcers can be painful, and this condition presents an increasing burden of care. A systematic analysis of the role of technology used for diagnosis and management strongly supports the use of compression as a mainstay of standardised care. It further shows good evidence for the potential of some treatment procedures to accelerate healing. This article reviews the pathogenetic mechanisms, current diagnostic methods and standard care and its limitations.

Keywords: Lipodermatosclerosis; Microcirculatory dysfunction; Technology guidelines; Venous hypertension; Venous ulcer.

Conflict of interest statement

Written informed consent was obtained from the patient for publication of this review and any accompanying images. Acopy of the written consent is available for review by the Editor-in-Chief of this journal.RM has received educational grants from the industry to conduct studies and to present lectures. The other authors declare that they have no competing interests.

Figures

Fig. 1

Prevalence of venous leg ulcers (VLUs) in different countries across the world. A darker colour is used to represent higher prevalence. (Prevalence was reported per 1000 individuals per year)

Fig. 2

a Typical appearance of patient with lipodermatosclerosis. The skin is flaky and there is a brownish discoloration. The skin can have a waxy feel to it. b A venous ulcer on the medial aspect of the leg

Fig. 3

a A plain X-ray film of a patient with a long-standing venous leg ulcer (VLU). Notice the extensive loss of bone due to infection (osteomyelitis). On account of recurrent episodes of sepsis, the patient received a leg amputation. b A long-standing VLU almost across the lower calf region. Notice the raised edges of the ulcer: a biopsy to exclude cancer proved to be a squamous cell carcinoma

Fig. 4

Cartoon of the pathophysiology of venous leg ulcers (VLUs). a The effects of valve incompetence and b the effects on tissues that lead to lipodermatosclerosis, cell death and ulceration. (Figures a and b were reprinted with permission from Mani R. Chronic Wound Management—the Evidence for Change, Parthenon Press 2002; copyright 2002 by Mani)

Fig. 5

A mixed arterio-venous leg ulcers (VLUs) with dry, pigmented skin surrounding the ulcer (on the left) and an uncomplicated venous ulcer with a sloughy base (on the right)