Ulcers are breaks in the layers of the skin, which subsequently fail to heal spontaneously. They may be accompanied by inflammation. Sometimes the failure to resolve becomes long-term. This is known as Chronic Ulceration.
Whilst ulcers can occur anywhere, we shall limit this discussion to leg and foot ulcers.
Leg ulcers are a very serious condition that can be both soul destroying for the patient as well as being painful, unsightly and notoriously difficult to treat.
People with diabetes are at special risk of developing foot ulcers, and foot care is an important part of diabetes management.
The causes of leg ulceration?
In general, the reason for chronic leg ulceration is poor blood circulation with in the legs. These are known as Arterial and Venous Leg Ulcers. However there are a range of causes for that poor circulation. These include:
- Injuries – termed ‘Traumatic Ulcers’
- Diabetes – a combination of reduced blood circulation and loss of sensation due to nerve damage resulting in pressure ulcers
- Certain skin conditions and Tumours
- Vascular diseases; including stroke, angina, heart attack, all of which result in reduced circulation.
- Infections, which hamper the bodies own repair pathways.
Arterial leg ulcers.
These account for about 10 per cent of all incidences of leg ulceration. They can be painful, with the pain increasing when the legs are elevated or at rest The patent’s legs and feet often feel cold to the touch, with a bluish-white, shiny, appearance.
Pain is often alleviated by allowing gravity to improve the flow of blood to the legs, by sitting on the edge of a chair or bed with feet on the floor
The major cause for arterial leg ulcers is narrowing of the arteries – called ‘Atherosclerosis’.
This can be caused by a variety of risk factors, such as:
- Long-standing diabetes.
- High blood pressure
- Coronary heart Disease and thrombosis
- Rheumatoid Arthritis
As a result of the atherosclerosis, people with arterial leg ulcerations often suffer from intermittent claudication. This is cramp-like pains in the legs when walking as a result of inadequate blood supply.
Diabetes and leg ulcers. As well as arteriosclerosis, Diabetes can result in damage to the nerve endings with in the lower limb. This can have a two fold impact on ulceration: First, trauma to the limbs becomes more likely due to the lack of sensation, and second, since no pain is felt, the injuries can go untreated and chronic ulceration result.
Prevent of arterial leg ulcers. Some preventative options jump out at you:
Reduction in weight and fat intake, stopping smoking and increasing exercise act to reduce many of the risk factors shown above.
And, for those suffering from Diabetes, continued health-care monitoring to identify ulcer formation and other health complications as soon as possible and ensure early preventative treatment.
Venous leg ulcers
Venous leg ulcers represent by far the largest group of ulcer cases, accounting for approximately 70 per cent of all leg ulcers.
The sufferer presents with a swollen leg, with dry, itchy, sometimes brown, skin surrounding the ulcer. Eczema is a common complication and the ulcer may be weeping but, although it can look raw, is often painless unless there is associated infection.
Venous leg ulcers are common on the inside of the leg, above the ankle.
The most common cause of venous leg ulcers is failure of the valves connecting the superficial and deep veins. These valves are designed to ensure flow of blood from the superficial to the deep veins, form where it is pumped out of the leg
Valve failure causes the blood to flow from the deep veins back out to the superficial ones, which also causes varicose veins.
A range of predisposing factors can cause or worsen venous leg ulcers. These include:
- Trauma or Surgery
- Obesity and prolonged sitting or standing
- A blood clot in the deep veins (deep vein thrombosis).
- Inflammation in the veins (phlebitis),.
Prevention of leg ulcers is best achieved by increased exercise, especially movement of the calf muscles, weight reduction and reduced fat intake.
Support stockings (Compression Hosiery) may be useful, after medical approval. Compression Hosiery is avoid in arterial leg ulcers as it can further restrict the amount of blood reaching the extremity.
Diagnosis of leg ulcers The appearance and location of the ulcer is usually sufficient to determine the type of ulceration involved.
Follow-up examinations such as a Duplex Ultrasound scan can be used to identifying underlying problems such as Deep vein Thrombosis.
To check the degree of impairment of blood flow I the legs, the blood pressure of the legs is compared to that of the arm.
Treatment of leg Ulcers Vascular surgeons who deal with leg ulcers will want o know the underlying cause before they treat the ulcer itself. In many cases, there may be more than one cause
In many cases, successful treatment of the underlying cause will ensure the successful resolution of the ulceration. In the mean time it might be necessary to introduce a regime of wound cleaning and taking anti-inflammatory drugs to prevent exacerbation of the ulcers.
Vascular surgery may be necessary for arterial leg ulcers, to distend the artery diameter using ‘balloon angioplasty’ for instance, or more in-depth ‘by-pass surgery’..
Plastic surgery may be used to close the ulcer and assist in its healing and cosmetic appearance.
Leg ulcers may recur, particularly in the elderly, sometimes requiring years of treatment.
Whilst it is usually very clear who has an ulcer, it can be very difficult to assess patients to determine who is at risk of developing an ulcer.
However, with the improvement in vein surgery and patient awareness through the Internet it is becoming increasing evident that patients are researching their condition and seeking there own treatment options.
The people who are most at risk of ulceration are the people who have the underlying venous problem but are not on a treatment regime. For instance, those with failing valves in their veins, but no visible signs of varicose veins as yet. They might have inflammation of the skin and discoloration of the skins with red or brown patches apparent. This is called ‘Lipomatosclerosis’. If this staining is not treated, it progressively worsens and causes ‘Haemosiderin’, dark brown staining. If this is also left untreated then white patches form within the staining which break down and causes ulceration.