Aetiology Of Leg Ulcers Research Articles

The evolution of leg ulcer guidelines and recommendations.

Clinical guidelines aim to consolidate and incorporate the latest evidence and opinion to improve patient outcomes and reduce variations in practice. This article will examine the evolution of clinical guidelines and recommendations in leg ulcer assessment and management, from the seminal Royal College of Nursing clinical guideline (1998) to the current Leg Ulcer Recommendations from the National Wound Care Strategy Program (2023). The evolving definitions of leg ulcers will be discussed, as well as the multidisciplinary approach needed to manage the underlying aetiology of this condition. A national appetite for improving leg ulcer assessment and treatment, is being informed by clinical guidelines and recommendations. The cornerstones of assessment and management remain constant, although some fundamental elements around ankle brachial pressure index ranges, historically used to aid diagnosis of leg ulcer aetiology, have been omitted in the recent recommendations.

Etiology of Chronic Leg Ulcers in a Dermatologic Wound Clinic: A Retrospective Observational Study

BACKGROUND: Chronic leg ulcers affect approximately 1% to 2% of the European population, with an increasing prevalence. The treatment of chronic wounds is a socioeconomical problem worldwide. PURPOSE: The main purpose of the current investigation was to detect the etiology of leg ulcers treated in a dermatologic wound clinic from January 1, 2010, to December 31, 2019. METHODS: This retrospective observational study was performed at the Dermatologic Clinic of Spedali Civili in Brescia, Italy. The authors enrolled 465 patients with chronic leg ulcers. RESULTS: The 3 most represented causes of ulcers were vascular (238 patients, 51.2%), inflammatory (71 patients, 15.3%) and traumatic (43 patients, 9.3%). Altogether, a total of 13 different entities were identified as a cause of leg ulcer. CONCLUSION: Vascular genesis was the most common etiology of leg ulcers in this population, even though uncommon causes were also represented. These findings are in agreement with other studies reported in the literature.

Clinical profile of patients with leg and/or foot ulcers attending government hospital in North Canara: A descriptive study

Background: Lower limb ulcers occur due to various conditions such as atherosclerosis and other arterial disorders, venous insufficiency, diabetes, trauma, pressure sores, vasculitis and inappropriate management of acute wounds. Many a time, it’s difficult to ascertain the exact etiology of leg ulcers. A lot of patients, especially in rural India, cannot afford/avail many investigations and therefore clinical assessment may be the only tool available to manage the disease. Method: This was a cross-sectional study done in tertiary hospital of Karnataka for a period of two months. A Sample size of 75 was selected. Based on the data from previous two years obtained from Medical Record department. Informed consent of the patients was taken and a detailed history, a complete systemic examination and local examination of lower limbs including the ulcer was done.Ethical Clearance was obtained from the Institutional ethical Committee. Results: Majority of patients (40%) with leg ulcer presented during sixth decade with a male to female ratio of 2.7:1. The most common aetiological factor for ulcer was trauma and infection i.e 29.1% of each. 16.1% of patients had ulcer over gaiters area. Majority of patients came with complaints of wound with pain (54.4%). 77.2% pf the patients had pus discharge from the ulcer.Conclusion: Often a multi-factorial aetiology may be present, which requires a comprehensive assessment for correct diagnosis. Education and training is vital for all those involved in caring for patients with chronic ulceration.

Getting lower leg ulcer evidence into primary health care nursing practice: a case study

Venous leg ulcers (VLUs) are open lesions on the lower leg caused by venous disease, which are associated with high morbidity and pose a challenge to manage effectively (Scottish Intercollegiate Guidelines Network, 2010). Gold standard treatment for VLUs is graduated compression therapy to aid venous return. This paper presents an approach to the challenging management of VLUs that is based on a problem, and subsequent local audit. We use a case study that illustrates a collaborative approach to determine gaps in evidence-based practice (EBP), and a nurse-led initiative in consultation with executive managers and doctors. In our sample, 40% of patients had not consulted a vascular specialist. They did not have a formal diagnosis of leg ulcer aetiology and therefore had not received optimum treatment. Access and cost were main factors impacting on leg ulcer care. Nurses providing evidence-based management of VLUs should ensure collaboration with key stakeholders. This assists in implementing diagnosis of ulcer aetiology for best practice measures. At this local health district, a change in policy to reflect EBP for VLU management in primary health care has been achieved.

Changes in the Aetiological Spectrum of Leg Ulcers after a Broad-scale Intervention in a Defined Geographical Population in Sweden

Objective: The study aims to compare the spectrum of leg ulcer aetiology in Skaraborg County in 1988 and 2002, an evaluation of 14 years of targeted leg ulcer intervention. Design: Cross-sectional study within the professional health-care system in Skaraborg County. Materials: In 2002, 621 leg ulcer patients were identified through a cross-sectional population survey. Methods: Half of the registered patients were randomly selected and offered clinical examination. A total of 198 patients with 246 legs underwent examination and were categorised in detail according to aetiology. Data were compared with the initial study in 1988. Results: Venous incompetence was present in 140 (57%) legs and the dominating cause in 94 (38%) of the leg ulcers, 40 (16%) due to deep venous incompetence. Arterial insufficiency was identified in 90 (37%) legs and the dominating aetiological factor in 41 legs (17%), eight (3%) being critical ischaemic ulcers. The relative risk (RR) of developing a leg ulcer in 2002 vs. 1988 was 0.77. The RR of a venous ulcer was reduced by 46%, arterial by 28%, while there was an increase in diabetic ulcers by 29% and multifactorial by 42%. Conclusion: The aetiological spectrum of leg ulcers has changed, most likely due to a new management strategy in the care of leg ulcer patients.

Changes in the Aetiological Spectrum of Leg Ulcers after a Broad-scale Intervention in a Defined Geographical Population in Sweden

ObjectiveThe study aims to compare the spectrum of leg ulcer aetiology in Skaraborg County in 1988 and 2002, an evaluation of 14 years of targeted leg ulcer intervention. DesignCross-sectional study within the professional health-care system in Skaraborg County. MaterialsIn 2002, 621 leg ulcer patients were identified through a cross-sectional population survey. MethodsHalf of the registered patients were randomly selected and offered clinical examination. A total of 198 patients with 246 legs underwent examination and were categorised in detail according to aetiology. Data were compared with the initial study in 1988. ResultsVenous incompetence was present in 140 (57%) legs and the dominating cause in 94 (38%) of the leg ulcers, 40 (16%) due to deep venous incompetence. Arterial insufficiency was identified in 90 (37%) legs and the dominating aetiological factor in 41 legs (17%), eight (3%) being critical ischaemic ulcers. The relative risk (RR) of developing a leg ulcer in 2002 vs. 1988 was 0.77. The RR of a venous ulcer was reduced by 46%, arterial by 28%, while there was an increase in diabetic ulcers by 29% and multifactorial by 42%. ConclusionThe aetiological spectrum of leg ulcers has changed, most likely due to a new management strategy in the care of leg ulcer patients.

Resting Doppler ankle brachial pressure index measurement: a literature review

Peripheral vascular disease (PVD) is under-diagnosed in primary and acute settings. The use of Doppler ankle brachial pressure index (ABPI) is effective in diagnosing PVD , aid in determining aetiology of leg ulcers and is cost efficient in reducing the effects of atherosclerosis and cardiovascular events. The aim of this literature review was to review practitioners' experience in using Doppler ABPI, different skills used to measure ABPI and to examine practitioners' confidence in ABPI. The findings identified variation in method for Doppler measurement: including position of the artery, arm measurement, resting period and type of equipment for measuring blood pressure, variations in practitioners' training and experience have demonstrated variability in ABPI results. Although limited in number, the studies have demonstrated knowledge gap, and the need for training among health professionals.

Prevention and treatment of venous ulcers in primary chronic venous insufficiency

Prevention and treatment of venous ulcers in primary chronic venous insufficiency

Microbial investigation of venous leg ulcers

To investigate microbiology laboratory reporting policies, whether practitioners working in primary care adhered to the relevant guidelines when submitting swabs from venous leg ulcers (VLUs), and the impact of laboratory reports on antibiotic usage forVLUs. Questionnaires were sent to all microbiology laboratories in England and Wales, and to clinicians who had submitted VLU swabs to one laboratory. Ninety-five (47%) laboratories responded. Laboratories processed a mean of 7.3 leg ulcer swabs/100,000 population/week but were often unable to identify the leg ulcer aetiology from the clinical details provided. All laboratories stated that they routinely reported group A haemolytic streptococci and meticillin-sensitive and resistant Staphylococcus aureus; 75% always reported antibiotic susceptibility for these isolates. The majority reported other beta-haemolytic streptococci. A total of 126 clinicians (64%) returned their questionnaires; 100 had confirmed in their swab submission that the ulcer was of venous aetiology and so were included in the analysis. Eighty per cent of the swabs were submitted in accordance with guidelines, with increased pain (61%) being the most common reason. Discharge/exudate (52%) and malodour (41%) were common reasons for swab submissions, even though the guidelines do not cite them as clinical signs of infection. Reporting of antibiotic susceptibilities was associated with increased antibiotic usage. Clinicians in primary care generally adhere to guidelines when submittingVLU specimens for microbiological investigation. Clinicians need to include clinical information with the swab so that laboratories can interpret the microbiology results. To reduce the use of antibiotics in the management ofVLUs, laboratories need to be selective in their organism and antibiotic-susceptibility reporting.

The effect of varying cuff position on recording ankle systolic blood pressure.

Ankle brachial pressure index (ABPI) aids the diagnosis of leg ulcer aetiology, although there is potential for patient anxiety or discomfort when the cuff is placed over an ulcerated ankle. This study aimed to ascertain any differences in systolic pressure if the cuff is positioned proximal to the ankle and to determine the feasibility of varying the cuff position to avoid ulcerated areas. The systolic blood pressure in the lower limbs of healthy volunteers (n = 60) was measured with the cuff at two discrete sites on the lower limb. There was a statistical difference in systolic blood pressure readings between the two sites (0-4 mmHg; p = 0.02) and a statistically significant ABPI difference (-0.08 to 0.05; p < 0.002). Blood pressure recording is subject to considerable variation in clinical practice and the ABPI has to vary by more than 0.15 to be clinically significant. Therefore, the differences in systolic pressure between sites and the ABPI calculations are not clinically significant in this study. An additional finding was that some subjects found the upper cuff position uncomfortable during the procedure.

Prevalence and aetiology of leg ulcers in Ireland.

The prevalence of leg ulcer disease in Ireland has been poorly documented. This study aimed to investigate the aetiology and prevalence of leg ulcers in one health district. All patients receiving healthcare for an active leg ulcer in the Mid-Western Health Board (MWHB) region of Ireland (population: 317,069) were identified in a defined two-month period. A cross-sectional survey of all healthcare workers providing care to patients with leg ulceration was carried out. Patients with leg ulcers of uncertain cause were invited for follow-up assessment to establish the underlying cause. There were 389 patients with leg ulcers with a mean (standard deviation [SD]) age of 72.3 (11.1) years. The prevalence was 0.12% but it was 1.03% in patients aged 70 years and over. Women were twice as likely to be affected. Venous disease accounted for 81% of ulcers, and arterial disease for 16.3%, while ulceration due to diabetic neuropathy and rheumatoid vasculitis was unusual. Leg ulcers are an important source of morbidity in our ageing population. Effective treatment programmes could diminish the impact of this debilitating disease on the health service.

Chronic wounds and nursing care.

This study has collated data on the prevalence of chronic wounds and the demography of patients with these wounds. Diagnostic methods, nursing care, the presence of diabetes and pain are analysed, as well as data on healing, amputation and mortality three months post-study. A total of 694 patients were identified: 406 with leg or foot ulcers, 117 with pressure ulcers and 171 with other wounds. Most patients were treated in the community. Leg ulcer aetiology was verified with ultrasound Doppler examination. There was a correlation between low Norton score (< 20) and severity of pressure ulcer (Stage III or IV). The use of 113 different wound dressings or combinations of products was reported. Time spent on dressing changes was the equivalent of full-time employment for 57 nurses. Wound cleansing was not predominantly performed with tap water, as recommended, but with saline. Almost all patients with venous leg ulcers (88%) were treated with compression but in 35% of these support stockings were used. Pain was present in almost half of all patients, more commonly in Stage III or IV pressure ulcers than in Stages I and II, and was most often reported in older patients. Diabetes was present in 25% of all patients with leg and pressure ulcers, and in 57% of patients with foot ulcers. At three-month follow-up, 28% of pressure ulcers, 40% of leg ulcers and 61% of other wounds had healed. Mortality was 35% in patients with pressure ulcers, 4% in those with leg ulcers and 7% in those with foot ulcers. These data have been presented to politicians in the county, resulting in allocation of resources for a wound healing centre.

Improving the Diagnosis of Chronic Leg Ulcers: A One-Stop Vascular Assessment Clinic in a Community Service

Objective: To evaluate the influence of a specialized vascular-led community leg ulcer service on assessment and diagnosis of leg ulcers. Design: Before-and-after study with prospective and retrospective data collection. Setting: East Gloucestershire, England, UK. Subjects: Patients treated for chronic leg ulcers before and within a specialized service incorporating a one-stop assessment including ankle–brachial pressure index (ABPI) and colour venous duplex. Main outcome measures: The means of assessment and the identified aetiology of leg ulcers in community patients. Results: Before clinics, only 40 (26%) limbs had a diagnosis recorded. After clinics, 83 (21%) limbs had arterial disease, including 64 (16%) with mixed arterial/venous disease. Venous duplex identified 279 (70%) limbs with venous disease of which 121 (43%) had superficial venous disease alone. Conclusion: A one-stop assessment clinic with ABPI and colour venous duplex ultrasound within a specialized community service improves diagnosis of leg ulcers. This is essential before appropriate and safe management by specialist nurses in the community.

Understanding the aetiology of leg ulcers.

A review of studies of leg ulcer aetiology, highlighting attempts to define the condition from the clinical and aetiological viewpoints

Prevalence and Aetiology of Leg Ulcers in a Defined Population of Industrial Workers

Objective: To assess leg ulcer prevalence and aetiology in people below retirement age. Design: A validated cross-sectional questionnaire survey. Respondents with a history of leg ulcers were examined. Setting: A defined population of industrial workers. Subjects: All 2785 employees, aged 30–65 years, at the Volvo motor engine factories in Skövde were included. Men predominated (81%) and the median age was 44 years in both men and women. A questionnaire was used to select people with a history of ulceration. A leg ulcer was defined as ‘any wound below the knee (foot ulcers included) that did not heal within a 6-week period after onset of ulceration’. Main outcome measures: Point prevalence of open leg ulcers, overall prevalence of leg ulcer history and aetiological classification. Results: The overall response rate was 87%, and 131 out of 153 subjects with a ‘history of leg ulcers’ were examined (86%). In 98% of positive responders the answers were validated. The overall false-positive response rate was 64%. Fifty-four had a true history of ulcers, of whom 16 had open ulcers. Of the latter, 12 were self-caring (75%). Overall venous causation dominated (41%). The ratio of open to healed ulcers was 1:2. The point prevalence for open ulcers was 0.6% and the overall prevalence of ulcer history was 1.6%, if excluding pure traumatic ulcers. The point prevalence was tenfold higher in people aged below 50 years and seven times higher in the age decade 50–59 years if compared with previous estimates based on patients known to health-care professionals. Conclusion: Leg ulcer prevalence has been underestimated in people of working age because they are often self-caring. Since many ulcers have curable causes it is necessary to inform the public of the importance of seeking professional help early.

The aetiology and healing rates of chronic leg ulcers.

Data from published studies of leg ulcer aetiology concentrate on venous and arterial disease as the main aetiological factors. The records of 490 patients attending leg ulcer clinics over a two-year period in 1992 and 1993 were reviewed. Although 58% of the ulcers studied resulted from venous disease, the remainder were caused by a wide range of factors. Our venous ulcer healing rate of 53% at six months was not as impressive as other published data, although this can be accounted for. By comparing the management and outcome for ulcers of various aetiologies, it was shown that they require different methods of treatment, often including referral to another specialty. Ulcers also exhibit differential healing rates depending on the underlying aetiology. Some ulcer aetiologies, particularly vasculitis, present particular problems and have very poor healing rates.