Cause Of Leg Ulcers Research Articles

Management Of Leg Ulcers

In the United States, leg ulcers present a significant clinical problem, occurring at a rate of approximately 600,000 new cases per year. (1) The most common types are venous, arterial, and neuropathic ulcers. Venous hypertension is the primary culprit in venous ulcerations. Peripheral vascular disease due to atherosclerosis with microvascular or macrovascular changes leads to ischemic ulcers. Sensory impairment with loss of protective sensation in the foot and repetitive trauma lead to neuropathic ulcers. Unusual causes of leg ulcers must be considered in the differential diagnosis. To arrive at the diagnosis, the clinician must perform a thorough history and physical examination, and order relevant investigative studies. Good management of chronic leg ulcers depends on correction of identified underlying conditions, long-term multidisciplinary care effort, and integrating traditional and new wound-healing technologies. Most patients with chronic leg ulcers benefit from the use of compression bandaging at a level appropriate to their vascular status. Venous ulcers must be managed with an arsenal of strategies to control venous insufficiency, heal the wound, and prevent recurrence. Surgery with revascularization remains the treatment of choice for chronic ischemic leg ulcers. In the absence of vascular compromise, up to 90 percent of neuropathic ulcers will heal with proper ulcer debridement, treatment of infection, saline wet-to-dry dressings, and relief of weight from the ulcerated area. The available armamentarium for wound care includes over 2000 wound dressing products and elastic compression wraps. Chronic leg ulcer treatment options have been expanded by alternatives available to treating these wounds. These alternatives include hyperbaric oxygen therapy, bioengineered skin substitutes, recombinant platelet-derived growth factors and vacuum assisted wound closure. Patients with large leg ulcers may benefit from skin grafting. Other patients may benefit from ligation and stripping of superficial veins or subfascial interruption of perforating veins.

Skin allergy problems in patients with chronic leg ulcers

Although many causes of leg ulceration have been reported over 70% are related to venous insufficiency associated with venous hypertension. Contact sensitivity (allergic contact dermatitis) is a frequent complication in patients with chronic venous leg ulcers affecting between 51–81% of patients. Complications associated with contact sensitivity in patients with non-healing leg ulcers are increased morbidity due to eczema and irritation which may result in delayed healing. This article reviews the frequency of contact sensitivity. Research has shown that lanolin and topical antibiotics, such as neomycin and framycetin, are the most common leg ulcer sensitizers and should be avoided in treatment. Creams have also been shown to contain sensitizers and therefore ointments should be used in preference to creams. The avoidance of allergens is important in the prevention of contact sensitivity and the promotion of ulcer healing.

Optimal management of chronic leg ulcers in the elderly.

Chronic leg ulceration is a very common clinical problem in the elderly. Good management depends entirely on making an accurate diagnosis, and planning treatment after considering all aspects of patient well-being. All elderly patients with leg ulcers benefit from an assessment of their vascular status, since the effects of gravity influence treatment and healing irrespective of the diagnosis. The most common causes of ulceration are venous and arterial disease. Diabetes mellitus, pressure, vasculitis, metabolic abnormalities and skin cancer are all unusual causes of leg ulceration, but must be considered in the differential diagnosis. Almost all patients with ulcerated legs benefit from the use of compression bandaging at a level appropriate to their vascular status. In patients with venous ulcers, this can be achieved with a number of bandaging techniques; however, multilayer bandaging appears to be the most cost-effective means available, particularly when combined with community-based leg ulcer clinics. The effects of oral drug therapy for venous and arterial disease have been disappointing. Local dressings are important in ulcers that are not suitable for compression therapy. The choice of dressing depends on the nature of the ulcer and the tolerability of the dressing for the patient.

Management of the diabetic patient: causes of leg ulceration.

The diabetic patient is at risk of developing numerous complications, including foot ulceration. The ulcer may contain a neuropathic and ischaemic element. Regular preventive checks can assist in early detection of foot problems. Failing eye sight and absence of sensation often result in patients relying on the healthcare professional detecting abnormalities on their behalf. The long-term effects of foot ulceration in the diabetic patient are immobility, septicaemia and amputation. Treatment options exist for the neuropathic and ischaemic foot but they vary in complexity. Accurate assessment and early recognition of the clinical signs of neuropathy and ischaemic ulceration will ensure early detection and optimum treatment interventions for the diabetic patient.

Leg and foot ulcer patients. Epidemiology and nursing care in an urban population in south Stockholm, Sweden.

To study the prevalence, demography, perceived aetiology, level of care, treatment and nursing care of patients treated for leg and foot ulcers. Prospective survey of leg and foot ulcer patients, using a structured questionnaire consisting of 20 questions directed at nurses and doctors in 193 units, including both primary health care and hospital. South Stockholm Medical Area, Stockholm, Sweden. Two hundred and ninety-four patients with leg and foot ulcers were identified during the six-week study period. Demographic data of population, prevalence of leg and foot ulcers, level of care, economic aspects, treatment of ulcers, level of compression, characteristics of the ulcers, pain and analgesics. With a population of 241,804 in the area, the prevalence of leg and foot ulcer was 0.12%. The majority of patients (92%) were older than 65 years of age, median age 79.2 years. The commonest cause of leg ulceration, as estimated by the staff, was venous insufficiency (42%). The majority of patients were treated within the primary health care system, and only a minority were treated in hospital. Many different local wound dressings were used (n = 51). The majority of dressing changes were performed by auxiliary nurses (54%). Compression was practised in 86% of all cases diagnosed as venous ulcers. Pain was reported by staff in 47% of all patients with venous ulcers. No pain relief was given to 29% of all these cases.

Venous insufficiency is not the cause of leg ulcers in sickle cell disease

Leg ulcers are a well recognized complication of sickle cell disease that has been attributed to venous insufficiency. We studied 16 patients with sickle cell disease and active ulcers using venous pulse volume recordings and photoplethysmography (Doppler studies). Based on hemodynamic monitoring, all 16 patients exhibited rapid refilling times, findings that imply venous insufficiency but are also compatible with high-output syndrome or arteriovenous shunting. Direct invasive venous pressure measurements of these patients demonstrated normal pressures in all of the four patients tested. A different set of four patients underwent venography, which also failed to demonstrate venous incompetence. We hypothesize that anemia results in an increase in peripheral arteriovenous shunting in the extremities and that this, together with the high-output syndrome of sickle cell disease, produces plethysmography readings that may be confused with findings observed in venous insufficiency. We conclude that measurements of vascular stasis, as recorded by plethysmography, are usually misinterpreted in sickle cell disease. Normal manometric pressure readings and normal venographic studies suggest that venous insufficiency is not a primary factor in sickle cell leg ulcer formation.

Metabolic causes of leg ulcers

Of all the causes of leg ulcers, metabolic reasons are very few. Diabetic ulcers are the most common manifestation of metabolic causes. It is a very rare occurrence that the ulcer will be the sole or initial manifestation of the underlying systemic disease. Much more common is the history of very poorly controlled diabetes treated by oral agents or insulin. The serum glucose as well as the glycosylated hemoglobin is often accompanied by glycosuria. The duration of the diabetes is not a hard and fast clue as to the course of the diabetes. Rather, the patient's history will often be full of multiple failures at tighter control of the diabetes.

Leg ulcers caused by yaws and endemic syphilis

Treponematoses as a cause of leg ulcer is today an infrequent phenomenon and is reported sporadically. 1 Availability and widespread use of a large variety of potent antibiotics, improvements in living conditions, increased social awareness and hygiene, and worldwide improvements in medical care have all contributed to its containment. However, in the underdeveloped, third world countries, pockets of endemic treponematoses continue to persist. Of late, a resurgence of the disease appears to have occurred in Western and Central Africa, and in the Asia Pacific region, 2 7 following the easing of surveillance and control measures. The current concept as far as the classification of human-associated treponematoses is concerned is given in Table 1. 8,9

Surgical Management of Leg Ulcers

Before an ulcer is treated, a systemic work-up should be pursued to find the etiology. Treatment should be instituted to prevent more ulcers from occurring. However, once an ulcer has formed, good medical management is usually sufficient to heal an ulcer and prevent others from occurring. If the ulcer persists despite adequate medical treatment, then pinch grafting or split-thickness grafting are relatively simple techniques with good success rates.

Cutaneous mucormycosis: A rare cause of leg ulceration

Cutaneous mucormycosis followed trivial injury to the leg of a 72-year-old man. The lesion progressed rapidly requiring above-knee amputation.