Ulcers - venous
Description
- Commonest chronic lower limb ulcer (~70-80% of leg ulcers)
- From chronic venous hypertension -> tissue damage
- Typically gaiter region (medial > lateral malleolus)
Epidemiology
- Prevalence rises with age, ~1-3% >65
- F>M
- Strong association with obesity, prior DVT, varicose veins, immobility, multiparity
Aetiopathogenesis
- Valvular incompetence (primary or post-thrombotic) or calf muscle pump failure
- -> venous hypertension -> capillary leak, fibrin cuff, chronic inflammation
- -> lipodermatosclerosis, tissue hypoxia, ulceration
- Risk factors: DVT history, varicose veins, obesity, prolonged standing, immobility, reduced calf pump (ankle stiffness, neuromuscular disease)
Diagnosis
Clinical
- Irregular border, shallow, exudative, gaiter region
- Surrounding haemosiderin staining, lipodermatosclerosis, varicose veins, oedema, atrophie blanche
- Usually less painful than arterial (pain worse with dependency suggests mixed/arterial component)
Essential before compression
- ABPI - confirm arterial supply adequate before compression
- ABPI >=0.8 - compression safe
- ABPI 0.5-0.8 - modified/reduced compression, specialist input
- ABPI <0.5 - compression contraindicated - arterial disease dominant, refer vascular
- Duplex ultrasound - reflux mapping if considering intervention
- Consider biopsy if atypical, non-healing >3 months, or malignant change suspected (Marjolin ulcer)
Management
First-line
- Compression therapy - mainstay, multilayer bandaging or compression stockings once ABPI confirms safety
- Leg elevation, exercise (calf pump), weight management
- Moist wound dressing per exudate level; avoid topical antibiotics routinely
Adjuncts
- Venous intervention (endovenous ablation) - accelerates healing and reduces recurrence if significant superficial reflux, per vascular assessment
- Treat cellulitis if present - flucloxacillin/cefazolin per local guideline; colonisation is universal - do not treat swabs without clinical infection
- Pentoxifylline - adjunct in some (limited local availability/evidence weight)
Maintenance
- Lifelong compression stockings post-healing - reduces recurrence substantially
- Skin care - emollients, manage dermatitis (topical steroid for venous eczema)
Associations
- Varicose veins, prior DVT/post-thrombotic syndrome
- Obesity, immobility
- Venous eczema, lipodermatosclerosis
- Cellulitis (recurrent)
Natural history & complications
- Chronic, relapsing - recurrence common without maintenance compression (~70% at 1 year without stockings)
- Slow healing - weeks to months
- Malignant transformation (Marjolin ulcer) - rare but consider in non-healing/atypical long-standing ulcer -> biopsy
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