Cause Of Leg Ulcers Research Articles

Clinical analysis of leg ulcers and gangrene in rheumatoid arthritis

Leg ulcers are often complicated in patients with rheumatoid arthritis (RA), however, the etiology is multifactorial. We examined the cases of leg ulceration or gangrene in seven RA patients who were hospitalized over the past 3years. One patient was diagnosed as having pyoderma gangrenosum. Although vasculitis was suspected in three patients, no histological evidence was obtained from the skin specimens. In these patients, angiography revealed the stenosis or occlusion of digital arteries. In the remaining three patients, leg ulcers were considered to be due to venous insufficiency. Treatment should be chosen depending on the causes of leg ulcers.

A prospective pilot study of ultrasound therapy effectiveness in refractory venous leg ulcers

Venous insufficiency is the most common cause of leg ulcers in the United States. Venous leg ulcers cost the health care system billions of dollars annually, and healing rates are less than 70% with standard of care; therefore, new therapies are needed to increase healing times and minimize associated costs. Non contact ultrasound therapy has been used to treat a variety of chronic wounds including venous leg ulcers, and it is thought that ultrasound has an effect on decreasing the bacterial count in wounds, although the exact mechanism of action of ultrasound is yet to be determined. We conducted an open labelled pilot study of 10 refractory venous ulcers of large size to determine the effect of non contact ultrasound on wound closure, bacterial counts, expression of inflammatory cytokines and pain reduction. We lacked a sham control group but we compared the baseline and end of treatment assessments and noted the differences. We found a significant reduction in wound area (P = 0·0039) over the 4-week treatment period. We also found a decline in individual and total bacterial counts; however, these differences were not significant. For all patients, there was also a trend toward reduced inflammatory cytokine expression compared with baseline levels; however, this reduction did not reach statistical significance. Interestingly, there was a correlation between healing and change in cytokine expression, which showed statistically significance for tumour necrosis factor (TNF)-αP = 0·0395, IL-1a P = 0·0351, IL-6 P = 0·0508, IL-8 P = 0·0990. Pain as measured by the visual analogue scale (VAS) was reduced from 4 at the baseline to 2·7 by the end of the study. In conclusion, we found that patients treated with ultrasound therapy and compression therapy show clinical improvement over the course of 4 weeks and had a decrease in inflammatory cytokines, bacterial counts and pain.

Differential diagnosis and therapy of leg ulcers

A leg ulcer is a symptom and the treating physician needs to find out its origin by differential diagnostic approaches and procedures. The correct diagnosis leads to a specific therapy that ideally accelerates the healing of the ulceration. Identifying the pathogenesis of a leg ulcer is the first and main step towards healing. Although vascular diseases are the major causes of leg ulcers, one needs to consider, in addition to venous and arterial disorders, autoimmune, infectious, metabolic and neoplastic causes. The simple truth that one can only make a diagnosis that was considered holds particularly true in leg ulcers. The differential diagnostic considerations presented here appear in the daily routine of a dermatologist and the article provides help in diagnostic approaches and therapeutic decisions.

A systematic review of health‐related quality of life instruments used for people with venous ulcers: an assessment of their suitability and psychometric properties

To review the quality of life questionnaires used to measure the impact of venous ulceration and to evaluate their psychometric properties. Venous leg ulcers have a negative impact on quality of life. Health-related quality of life can be measured using structured questionnaires. Nurses are the primary care providers for patients with venous ulceration and are ideally placed to assess and develop these types of questionnaires. There may also be an opportunity to use such quality of life instruments to measure the impact of nursing interventions in other areas where nurses are the key care providers. Systematic review. Studies were sought that used quality of life instruments to evaluate the impact of venous ulceration. Fourteen electronic bibliographical databases and 11 Internet-based health services research related resources were searched. In addition, grey literature was sought and the reference lists of relevant articles checked. Data were extracted regarding the type of instrument used, sample, number of items and domains and psychometric performance of the instrument. The initial search identified a total of 338 potential citations. After review, a total of 31 studies were included: 17 used generic and 14 used disease-specific instruments. Five different types of generic and seven disease-specific instruments were identified. There was significant heterogeneity between the studies in terms of study design, aetiology of ulceration and times of assessment. The disease-specific instruments showed limitations in relation to their applicability to venous ulcer patients because of flaws in design or validation. The literature on quality of life related to venous ulceration failed to sufficiently distinguish between those with different causes of leg ulceration. There appeared to be problems with the ability of current quality of life instruments to detect changes in quality of life related to ulcer healing. Relevance to clinical practice. There appears to be an opportunity for nurses to develop a health-related quality of life health-related quality of life instruments to evaluate their impact on patient outcomes. Such instruments could potentially allow nursing interventions to be assessed more effectively than the recently proposed nursing metrics.

Mycobacterium chelonae: A rare but important cause of leg ulceration

Mycobacterium chelonae: A rare but important cause of leg ulceration

Contact Allergens in Persons With Leg Ulcers: A Canadian Study in Contact Sensitization

Individuals with chronic leg ulcers often develop contact allergic reactions to topical preparations used to treat their wounds and the surrounding skin. The objective of this study was to determine the frequency of positive patch test responses to common allergens in patients with leg ulcers or venous disease. A case series of 100 consecutive, consenting patients with chronic venous disease and other causes of leg ulcers that were available for patch testing were enrolled. The patients were tested with 38 common allergens, including those most relevant to leg ulcers. A total of 46% of the patients had at least 1 positive patch test response. Multiple reactions in the same patient were common. The most frequent groups of sensitizers were fragrances, lanolin, antibacterial agents, and rubber-related allergens. Though the prevalence of positive patch test reactions is high in this population, it is lower than commonly reported. This may be the result of clinical practice that considered the avoidance of common sensitizers in the management of patients with leg ulcers.

Endovascular Treatment of a “Fishy” Ulcer Caused by a Traumatic Arteriovenous Fistula

Arteriovenous fistula secondary to trauma is an uncommon cause of leg ulcers. In this article, an unusual case of a nonhealing leg ulcer caused by a stingray is described. This case highlights the difficulty in diagnosing and treating nonhealing ulcers secondary to arteriovenous fistula.

Healthcare beliefs of Indian patients living with leg and foot ulcers

This article presents the results of a previously unexplored aspect of qualitative leg ulcer research. The study has examined the lived experience and cultural illness explanations of a sample of British-Indian patients living with leg and foot ulceration. Semi-structured interviews were used to collect data from 16 Indian patients drawn from leg ulcer clinics and district nursing lists in Ealing Primary Care Trust and Hounslow Primary Care Trust. Eight respondents had venous ulceration, seven were diabetic and had ulcers of arterial aetiology, and one had ulceration due to lymphoedema. Popular perceptions of the cause of leg ulceration were influenced by the humoral theories of balance and imbalance. Other explanations included poor circulation, lowered immunity, bad blood, being cursed and doing something wrong in a past life or this life.

Case report and literature review of leishmaniasis as a cause of leg ulceration in the United Kingdom

Chronic leg ulceration is a common clinical problem in the UK, with a prevalence of more then 1% in the general population, rising to 2% in those over the age of 80. The commonest cause is mixed venous-arterial disease, which accounts for 67–76% of patients, with arterial disease being the cause in 9–28%. Less common diseases and presentations, such as vasculitis and malignancy, are the cause of ulceration in only 1–2% of patients (Table 1). All these ulcers are associated with considerable morbidity and the cost to the community in particular is high. It has been reported that 1.3% of the total health-care budget of the NHS is spent on the treatment of leg ulcers.

A Review of Technological Approaches to Venous Ulceration

Leg ulceration is a chronic condition affecting about 1-2% of the adult population. The main causes of leg ulceration are venous hypertension, arterial insufficiency, diabetes, or a combination of these aetiologies (causes) or malignancy. Venous ulcers account for approximately 80% of all leg ulcers and are a result of venous hypertension. The current mainstay of treatment of venous ulcers is the application of graduated compression bandaging to the limb. In spite of the application of the best evidence-based therapy, healing rates for venous leg ulcers remain disappointing, at 50-70% after 12 weeks of treatment, depending on initial size and chronicity of the ulcer. Thus, a large number of ulcers are unhealed by this time, and many patients suffer from long-term leg ulceration, some remaining for years, and those that heal often recur. There is an obvious need to develop new treatments that would improve healing rates. This review provides a complete overview of the anatomy of venous circulation and the physiology pertaining to it, the pathophysiology of venous disease, the pathogenesis of ulceration, and a review of treatments currently employed in healing venous leg ulcers and their supporting evidence. The aim of this article is to encourage a fresh look at this chronic problem and stimulate ideas on how healing rates can be improved.

Uncommon causes of leg ulceration and lesions not to be missed

While the vast majority of cases of leg ulceration are the result of venous and/or arterial disease, and occur in older people, there are several other, less common conditions that can lead to leg ulceration, often in younger people. This article examines the diagnosis and management of some of these conditions, almost all of which will require referral for specialist assessment and treatment.

Is this leg ulcer venous? Unusual aetiologies of lower leg ulcers

The overwhelming majority of ulcers (95%) are vascular in origin. Most of these are venous (70%), and the rest are arterial (10%) or of mixed aetiology. The remaining 5% have other causes. This paper provides an overview of these rarer causes of leg ulceration, which can result in complex cases.

Prevalence of leg ulceration in a London population.

Current prevalence estimates of chronic leg ulceration are frequently based on studies from the 1980s. During the last decade, major changes have occurred in the application of evidence-based practice to this condition. To determine the prevalence and cause of leg ulceration in a defined geographical population after 8 years of providing standardized evidence based protocols of care. Prospective survey. Patients with leg ulceration of >4 weeks duration) within an integrated acute and community leg ulcer service were ascertained, interviewed and clinically assessed, using a standardized questionnaire on medical history, ulcer details and non-invasive vascular investigation to describe causes. Ulcers were classified by aetiology. We identified 113 patients in a population of 252 000, giving a crude prevalence of 0.45/1000 (95%CI 0.37-0.54/1000): 0.34/1000 in men, 0.54/1000 in women. Rates were highly dependent on age, increasing to 8.29 (men) and 8.06/1000 (women) in those aged >85 years. Of the responders, 62/113 (55%) had their ulcer for >1 year. Uncomplicated venous ulceration was observed in only 59/138 (43%) ulcerated limbs; a further 21 had ulceration primarily due to arterial disease. Complex causes were present in 48 (35%) limbs, mostly venous disease in combination with diabetes (35%), lymphoedema (42%) and rheumatoid arthritis (26%). Our prevalence of chronic leg ulceration is approximately one-third of that predicted by previous studies using similar methodologies in the 1980s. Patients with ulceration have more complex aetiologies than previously recognized, which may be a consequence of both increasing ulcer chronicity and age.

Increased incidence of hypercoagulability in patients with leg ulcers caused by leukocytoclastic vasculitis

Vasculitis is a rare cause of leg ulceration. It is unclear why severe skin infarction develops in some patients with vasculitis, whereas others have only mild symptoms such as purpura, erythema, or urticaria. A coincidence of vasculitis and hypercoagulability may lead to more extensive thrombotic occlusion and hence explain the occurrence of large ulcers in a subset of patients. Our aim was to investigate whether patients with vasculitis ulcers have an increased incidence of hypercoagulability. Thirteen consecutive patients admitted to the hospital with necrotic ulcers caused by histologically confirmed vasculitis were screened for clotting disorders. In 7 of 13 patients (53%), hypercoagulable conditions were found. Five patients had factor V Leiden (38%), and 2 had lupus anticoagulant (15%). The normal frequency of these conditions is 5% to 6% and 3.6%, respectively. These data indicate that there is an increased incidence of hypercoagulable disorders in patients with vasculitis ulcers. We recommend screening these patients routinely for hypercoagulability.

Leg Ulcers of Unusual Causes

In this review, unusual causes of leg ulcers are examined with an emphasis on pathophysiology, clinical presentation, and epidemiology. Cutaneous ulcers due to malignancy of unusual leg ulcers with hematologic disorders, vasculitis, sarcoidosis, calciphylaxis, Buerger's disease, and pyoderma gangrenosum are discussed.

Leg ulceration as a long-term complication of deep vein thrombosis.

To evaluate the role of deep vein thrombosis as a cause of leg ulcers. A population-based, case-control study was conducted in Central and North Auckland, New Zealand. Cases comprised 241 people aged 40 to 99 years and on the electoral roll, with current leg ulcers (all types). Cases were identified by means of notification from health professionals and by self-referral. Controls were 224 people in the same age group, without leg ulcers, who were selected from the electoral roll by using a stratified random sampling process. The occurrence of leg ulceration as a consequence of exposure to deep vein thrombosis or being at high risk of deep vein thrombosis (that is, people with a family history of deep vein thrombosis, and/or a history of leg fracture and/or hip, leg, or foot surgery). After adjustment for age, sex, and other potential confounding factors, people who had a diagnosed thromboembolism were at almost three times higher risk of having a leg ulcer (odds ratio, 2.92; 95% confidence interval (CI), 1.47 to 6.08). In addition, people who had been at high risk of a venous thrombosis but were not diagnosed with this condition (eg, people with a history of major leg surgery) were also at increased risk of ulceration (odds ratio, 2.25; 95% CI, 1.49-3.42). Overall, 56% (95% CI, 33% - 71%) of leg ulcers were attributed to being at high risk of deep vein thrombosis. Deep vein thrombosis and factors that place people at high risk of deep vein thrombosis are an important cause of leg ulcers in older people. This finding strengthens the rationale for the routine and long-term use of thromboprophylaxis, particularly in high-risk patients.

Jobst UlcerCARE compression hosiery for venous leg ulcers.

Chronic venous insufficiency affects the productivity and well-being of millions of people worldwide and is the most common cause of leg ulcers. Treatment of leg ulcers accounts for 22% of district nurses' time and places a major financial burden on NHS resources. Compression bandaging has been recognized as the optimum approach for venous ulcers but is not always applied effectively. It is also costly and may lead to non-compliance. Compression hosiery is an alternative treatment approach. Review of relevant research shows JOBST UlcerCARE to be an effective treatment that is easy to apply, thereby maintaining patient independence. It also provides a major potential for cost savings to the NHS.

Does severe venous insufficiency have a different etiology in the morbidly obese? Is it venous?

Chronic venous insufficiency (CVI) is the most common cause of leg ulcers. Patients with morbid obesity are remarkable for particularly recalcitrant ulcers. Because obesity is not specifically incorporated in CEAP or other venous scoring systems, we sought to characterize this group of patients more completely. Patients with severe CVI (CEAP clinical class, 4, 5, and 6), and class III obesity (body mass index [BMI], >40) were reviewed. Findings from clinical and duplex ultrasound scan (DU) examinations were compared with the CEAP classification, its adjunctive venous clinical severity score, and sensory thresholds. A review of clinic records identified 20 ambulatory patients with a mean age of 62 years, a mean BMI of 52, and a mean weight of 164 kg (361 lbs); all but one had bilateral symptoms. No evidence of venous insufficiency was detected with DU in 24 of the 39 limbs. Although some valvular incompetence was detected with DU in 15 of 39 limbs, these abnormalities were widely dispersed between 28 sites; eight limbs had findings at only one site. Ulceration (mean area, 29 cm(2)) was present in 25 limbs and necessitated 7 months for healing; 13 (52%) recurred at least once during a mean observation period of 36 months. The mean sensory threshold of 5.21 exceeded current risk thresholds used in diabetic screening programs. The distribution of CEAP clinical class was C4 (n = 14), C5 (n = 14), and C6 (n = 11). Increasing CEAP class correlated with an increased mean BMI of 47, 52, and 56, respectively (P <.01). CEAP also correlated with a rising mean venous clinical severity score of 10, 11, and 15, respectively (P <.05). Patients with class III obesity had severe limb symptoms, typical of CVI, but approximately two thirds of the limbs had no anatomic evidence of venous disease. The association of increasing limb symptoms with increasing obesity suggested that the obesity itself contributes to the morbidity.

65-Year-Old Woman With Painful Leg Ulcers

65-Year-Old Woman With Painful Leg Ulcers

Diagnosis 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.