Chronic Ulcers

What are Chronic Ulcers?

Chronic ulcers are areas on the legs, ankles or feet where underlying tissue damage, or a trauma, has caused skin loss, leaving a raw wound that takes a long time to heal.

Chronic ulcers can develop for numerous reasons. They are one of the effects of chronic venous insufficiency, a term used to describe disease in the tissues of the leg resulting from prolonged high pressures in the veins of the leg.

This high pressure occurs due to abnormal backward flow of blood (reflux), caused by the incomplete pumping action of the valves within the veins. High pressure can also be caused by venous blockages.

What causes Chronic Ulcers?

There are some unavoidable factors that appear to increase the risk of chronic venous insufficiency, and therefore chronic ulcers, including:

• Age
• Family history

As well as correctable factors such as:

• Varicose veins/Chronic Venous Insufficiency
• Peripheral Arterial Occlusive Disease
• Being overweight
• Being physically inactive
• Smoking
• Ankle and leg swelling from other causes
• For women, standing for long periods of time

Diseases of the veins and diseases of the arteries are two common causes of chronic ulcers, as these can compromise blood supply to the affected area and therefore the body’s ability to heal. Diabetes mellitus and diabetes are another cause of ulceration. Sometimes skin cancers can cause ulcers, but the majority of ulcers in the leg are not skin cancer.

Chronic ulcers affect approximately 0.1-0.2% of the general population. Approximately 10-20 people per 1000 develop ulcers during their lifetime.

What are the signs/symptoms of Chronic Ulcers?

The most obvious sign of a chronic ulcer is the ulcer itself. This will be an area on the leg, ankle or foot where there is skin loss, leaving the area raw, and not healing like a cut or graze.

Other signs and symptoms include:

• Swelling
• Heat and inflammation in the affected area
• Pain
• Brown pigmentation of the skin near the ankles

In many patients varicose veins will also be present in conjunction with chronic venous insufficiency, but this is not always the case.

Is it a graze or a chronic ulcer?

Chronic ulcers differ greatly to skin grazes. The distinction is important.

Chronic ulcers are difficult to treat, and are very slow healing because they contain no skin cells within the ulcerated area. The only way the skin can seal the ulcer is to close in on it from the outside in - a big feat considering how large ulcers can grow.

Grazes can be shallow, or deep enough to cause bleeding, but if cleaned and protected, will quickly build skin cells across the wound and from within, sealing themselves over 5-10 days.

How will Chronic Ulcers affect my health?

Having a chronic ulcer is a stubborn and long-term health issue and requires dedication on behalf of the patient and the treating doctors and nurses to fully heal the ulcer and have it not recur. Even with ongoing professional treatment, healing rates are poor, with up to 50% of venous ulcers remaining present and unhealed after 9 months.

Recurrence is a significant concern, with up to a third of ulcer patients on their fourth, or more, episode.

Added to these issues, treatment is costly. Together, these issues affect quality of life for individuals with chronic ulcers.

When the chronic ulcers have healed to a certain point, compression stockings should be worn every day. The stockings need to be washed and maintained to stay effective. If you are prescribed to wear compression stockings, it is vital to do so diligently. It is a small, but very important lifestyle commitment. Patients who do wear compression stockings every day, reduce their chance of having a recurring ulcer to 32% over 5 years, versus 69% for people who do not reliably wear compression stockings. This depends entirely on the cause of the ulcer and not appropriate for all.

Rarely, a long-standing leg ulcer may develop into a skin cancer, usually a squamous cell carcinoma, commonly known as a Marjolin's ulcer.

What are the stages of Chronic Ulcers?

Chronic venous insufficiency (CVI) is the cause of chronic ulcers, therefore the early stages of chronic venous insufficiency may indicate the commencement of a chronic ulcer.

The stages of CVI, in no particular order, include:

• Pigmentation - a brown discolouration of the skin above the ankle, caused by leakage of blood cells out of blood vessels.
• Lipodermatosclerosis - thickening skin, that feels hard, not like usual suppleness and pliability. The veins can also feel hard to the touch.
• Varicose Eczema - the skin can appear red, wet, scaly, or ‘angry’.
• Swelling - the leg above the ankle swells, giving the appearance of an inverted champagne bottle.

Ulceration can occur as an early stage or later stage symptom of chronic venous insufficiency.

I think I have a Chronic Ulcer – What should I do?

The best form of treatment for your leg ulcer will depend on exactly why the ulcer has occurred. An accurate diagnosis is necessary, therefore you should:

• Visit your GP: Request a referral to a Vascular Surgeon.
• Visit a Vascular Surgeon: During your visit, your accurate medical history will be recorded and you will undergo a physical examination with special reference to venous and arterial disease, diabetes and rheumatoid arthritis. You will also undergo an assessment of veins as well and a swab/biopsy of wound will be taken to identify infection or malignancy.
• It is very important to disclose your full medical history with the surgeon, because seemingly small details can be pivotal in the correct diagnosis of your chronic ulcer. Please inform the surgeon of previous:
  • Minor injuries (because many ulcers begin as very minor injuries that would normally be expected to heal)
  • Venous or Arterial surgeries
  • Lower body surgeries (leg, knee, ankle, foot)
  • Cramps
  • Problems with your mobility
  • DVT
  • Varicose vein surgery
  • Skin cancers

The vascular surgeon will refer you to have, or will perform themselves, a formal assessment of the arterial circulation using the hand-held Doppler and measurement of the ankle-brachial index. This instrument is a very sensitive tool for assessing blood flow in the leg, which is then compared against the blood flow in the arm. The blood flows are usually the same, so if the index is different to 1.0, it will indicate an abnormality to further explore.

The surgeon may also recommend that you undertake a duplex scan (venous incompetence ultrasound) of the limb veins. This ultrasound scan will clearly identify patterns of venous reflux that can be surgically corrected in appropriate patients.

During the physical examination of the ulcer, the doctor may take a biopsy or swab to check for underlying skin cancer, or to help diagnose other underlying causes of the ulcer.

What if I don’t have my Chronic Ulcers treated?

Risk of infection (and septicemia) and deterioration of the ulcer itself (larger and deeper) are risks of leaving ulcers untreated. The other consequences are dependent on the underlying cause ie; PAOD, VV, malignancy or diabetes.

What treatment options does SVS offer for Chronic Ulcers?

At Sydney Vascular Surgery we offer solutions when the cause of your chronic ulcer is due to compromised venous and/or arterial supply. It would be good to include links here to Varicose Veins treatments and PAD treatments

We also provide a vascular surgeon service to the Lady Davidson Wound Clinic where the expert team of wound nurses manage chronic ulcers of all kinds. They can be contacted on: (02) 9488 0257 or call Sydney Vascular Surgery on: (02) 9439 8715.

Our doctors can provide you with thorough information on conservative management practices, and can equip you with a wound dressing regimen.

Using appropriate wound dressing techniques consistently has been shown to help 50-70% of purely venous ulcers heal within 12 weeks.

Despite intensive treatment there will still be some patients who are left with intractable ulcers that fail to heal. Some patients require protracted multidisciplinary care. In these circumstances SVS will continue treating the ulcer with the aim to keep the ulcer under control and collaborate with other doctor’s involved in the patient’s care, including:

• Microbiologist/infectious diseases physicians (to manage any infections)
• Endocrinologists (when diabetes plays a role)
• Plastic surgeons (when skin grafts are required)

All of these doctors are committed to reducing the impact of chronic ulcers on the day-to-day life of the patient as much as possible.

Helpful Links:

http://www.anzsvs.org.au/patient-information/chronic-venous-insufficiency-and-leg-ulcers/