Venous ulcers

• most common cause of lower extremity ulcer
• Location: Low on the medial ankle over a perforating vein,  along the line of the long or short saphenous veins
• multiple or single
• typically tender
• Shallow
• red-based, or occasionally exudative
• ulcer borders : irregular, not undermined

Treatment for stasis ulcers

• Compression
  • Compression is a mainstay of treatment for stasis ulcers.
    • Compression (eg, four-layer elastic bandaging) helps heal stasis ulcers, limits leg swelling and provides symptomatic relief.
    • Compression stockings are less effective in the treatment of established ulcers but are useful for wound prevention
• Local wound care
  • Adequate wound care involves keeping the wound clean and moist with regular dressing changes.
  • Debridement is used to remove dead tissue along the borders of the wound and excessive slough from the wound bed.
  • Treat venous eczema with topical steroids and regular emollients.
• Medical and surgical treatment
  • Oral medications that affect blood flow, particularly aspirin, provide some benefit in promoting the healing of stasis ulcers.
  • Surgical interventions may help stasis leg ulcers heal and prevent their recurrence.
    • Superficial vein ablation reduces the backflow of blood from deep penetrating veins to superficial leg vessels; see leg vein therapies.
    • Skin grafting may be required for stable, uninfected, large stasis ulcers who have not shown improvement with other measures.
• In the case of a resistant stasis ulcer, other therapies may be tried, including:
  • Hyperbaric oxygen therapy
  • Medications that cause venous constriction, including flavonoids
  • Medications that affect blood flow, such as pentoxifylline
  • Therapeutic ultrasound and electromagnetic therapy. 
• What is the outcome for stasis ulcers?
  • Stasis leg ulcers are chronic and may persist for a few months to many years. Once they have healed, there is a high likelihood that stasis ulceration will recur, unless the underlying venous insufficiency is effectively treated.

factors delaying healing venous ulcers

1. ↓ blood supply to the area(atherosclerosis, DM)
2. Infection of the ulcer
3. Immobility – ↓ calf activity
4. At high pressure areas – healing delayed due to increased movement
5. Immunodeficiency –steroids, DM, HIV
6. Underlying venous disease/ malignancy. Blood disorders(haemophilia, leukemia), Liver Disease
7. Age/ Nutrition status

Differential diagnosis of arterial, venous, and neuropathic foot ulcers 

Characteristic	Arterial ulcer*	Arteriolar infarct	Venous ulcer	Neuropathic ulcer*	SCC/BCC
	10%		10%
Location	Toes or pressure points  over bony prominence	Lateral aspect	Lower medial side Malleolar metatarsal	Underneath the foot Often on sole, over boney prominences	Sun exposed
Size	Small		Vary in size, circumferential or discrete
Appearance	Irregular margin		Irregular margin, may be exudative
depth	Deep		Shallow	Deep
Edge	Punched out		Uneven, granulation tissue at the edge	Punched out	SCC: Everted BCC: rolled
Floor	pale or cyanotic Dry/necrotic/black no granulation		Pink base Fibrinous exudate & ooze Purulent fluid Red granulation tissue	infected Yellow slough Bone may be exposed	Irregular Necrotic slough in base hemorrhagic
Surrounding skin	Cold  Thin Shiny hairless		Venous spots Hemosiderosis Lipodermosclerosis Pitting Odema Dermatitis Atrophic banche	Signs of arterial disease	Is healthy with good circulation
Foot temperature	Cold and dry		Warm	Warm and dry
Pain	Present, may be severe Lifting:  ↑pain	intense	Mild Lifting:  ↓pain	Absent	Absent
Arterial pulses	Absent		Present	Present or absent
Veins	Collapsed		Dilated, varicosities pigmentation and edema (worse when dependent)	Dilated
Sensation	Variable		Present	Loss of sensation, reflexes, and vibration sense
Ulcer within callus	Absent or infrequent		Absent	Present
Foot deformities	Absent		Absent	Often present

* Diabetic foot ulcers are often due to both arterial disease (involving the microcirculation as well as large vessels) and neuropathic disease