Lower Extremity Ulcers of the Legs, Ankles, and Feet

An ulcer is a sore on the skin or a mucous membrane often associated with the disintegration of tissue and the formation of pus. Ulcers can result in the complete loss of the epidermis, the dermis, and in more advanced cases subcutaneous fat. Ulcers that appear in the skin are distinguished by inflamed tissue with an area of reddened skin. Skin ulcers are most often associated with diabetes, but have numerous other causes including exposure to heat or cold, irritation, and problems with blood circulation.

Lower extremity ulcers and amputations are an increasing problem among individuals with diabetes. Data from the 1983-90 National Hospital Discharge Surveys (NHDS) indicate that 6% of hospitalizations listing diabetes on the discharge record also listed a lower extremity ulcer condition. In hospitalizations that listed diabetes, chronic ulcers were present in 2.7% of the patients. The average length of stay for diabetes discharges with ulcer conditions was 59% longer than for diabetes discharges without ulcers. Recent data suggest that foot ulcers precede approximately 85% of nontraumatic lower extremity amputations (LEAs) in individuals with diabetes.

More than half of lower limb amputations in the United States occur in people with diagnosed diabetes. NHDS data also indicate that there were  about 54,000 diabetic individuals who underwent  nontraumatic LEAs in 1990. Lower extremity amputations are more common in individuals with diabetes than without diabetes.

Several studies have demonstrated the beneficial effect of patient education on reducing LEAs. A randomized trial showed that patient self-care was helpful in preventing serious foot lesions. Several amputation prevention programs have reported striking pre- and post-intervention differences in amputation frequency after instituting comprehensive, multidisciplinary foot care programs. Part of the hospital care and self care program should be the administration of a topical growth factor gel to the wound.

What are the types and symptoms of ulcers? Ulcers may or may not be painful. The patient generally has a swollen leg and may feel burning or itching. There may also be a rash, redness, brown discoloration or dry, scaly skin. The three most common types of leg and foot ulcers are:

  1. Venous stasis ulcers
  2. Arterial (ischemic ulcers)
  3. Neurotrophic (diabetic ulcers)

Ulcers are typically defined by the appearance of the ulcer, the ulcer location, and the way the borders and surrounding skin of the ulcer look as defined below:

1. Venous stasis ulcers

Venous ulcers are located below the knee and are primarily found on the inner part of the leg, just above the ankle. The base of a venous ulcer is usually red and may also be covered with yellow fibrous tissue, or there may be a green or yellow discharge if the ulcer is infected. Fluid drainage can be significant with this type of ulcer.

The borders of a venous ulcer are usually irregularly shaped and the surrounding skin is often discolored and swollen. It may even feel warm or hot. With edema (swelling) the skin may appear shiny and tight. The skin of the lower leg may also have brown or purple discoloration known as “stasis skin changes.”

Venous stasis ulcers are common in patients who have a history of leg swelling, long standing varicose veins, or a history of blood clots in either the superficial or the deep veins of the legs. Ulcers may affect one or both legs.

Venous ulcers affect 500,000 to 600,000 people in the United States every year and account for 80 to 90% of all leg ulcers.

2. Arterial (ischemic)

Arterial ulcers are usually located on the feet and often occur on the heels, tips of toes, between the toes where the toes rub against one another or anywhere the bones may protrude and rub against bed sheets, socks or shoes. Arterial ulcers also commonly occur in the nail bed if the toenail cuts into the skin or if the patient has had recent aggressive toe nail trimming or an ingrown toenail removed.

The base of an arterial or ischemic ulcer usually does not bleed. It has a yellow, brown, gray, or blackened color. The borders and surrounding skin usually appear as though they have been punched out. If irritation or infection are present, there may or may not be swelling and redness around the ulcer base. There may also be redness on the entire foot when the leg is dangled; this redness often turns to a pale white/yellow color when the leg is elevated.

Arterial ulcers are usually very painful, especially at night. The patient may instinctively dangle their foot over the side of the bed to relieve the pain. Patients usually have prior knowledge of poor circulation in their legs and may have an accompanying disorder.

3. Neurotrophic (diabetic)

Neurotrophic ulcers are usually located at increased pressure points on the bottom of the feet. However, neurotrophic ulcers related to trauma can occur anywhere on the foot. These types of ulcers occur primarily in people with diabetes although anyone who has impaired sensation of the feet can be affected.

The base of the ulcer is variable, depending on the patient’s circulation and may appear pink/red or brown/black. The borders of the ulcer are punched out and the surrounding skin is typically calloused.

Neuropathy and peripheral artery disease are often co-morbid in people who have diabetes. Nerve damage (neuropathy) in the feet often results in a loss of foot sensation and changes in the sweat-producing glands. Thus, a person may not feel the development of foot calluses or cracks, increasing the risk of injury or infection. Symptoms of neuropathy include tingling, numbness, and burning or pain.

What causes leg ulcers? Leg ulcers may be caused by:

  1. Poor circulation, often caused by arteriosclerosis
  2. Diabetes
  3. Venous insufficiency (a failure of the valves in the veins of the leg that causes congestion and slowing of blood circulation in the veins)
  4. Other disorders of clotting and circulation that may or may not be related to atherosclerosis
  5. Renal (kidney) failure
  6. Hypertension (treated or untreated)
  7. Lymphedema (a buildup of fluid that causes swelling in the legs or feet)
  8. Inflammatory diseases including vasculitis, lupus, scleroderma or other rheumatological conditions
  9. Other medical conditions such as high cholesterol, heart disease, high blood pressure, sickle cell anemia, bowel disorders
  10. History of smoking (either current or past)
  11. Pressure caused by lying in one position for too long
  12. Genetics (they may be hereditary)
  13. A malignancy (tumor or cancerous mass)
  14. Infections
  15. Certain medications

How are leg ulcers diagnosed and treated?

First, the patient’s medical history is evaluated. A wound specialist will examine the wound thoroughly and may perform tests such as X-rays, MRIs, CT scans and noninvasive vascular studies to help develop a treatment plan. The goals of treatment are to relieve pain, speed recovery, and heal the wound. Each patient’s treatment plan should be individualized based on the patient’s health, medical condition, and ability to care for the wound.

Treatment options for all ulcers may include:

  1. Antibiotics, if an infection is present
  2. Anti-platelet or anti-clotting medications to prevent a blood clot
  3. Topical wound care therapies (including topical growth factors)
  4. Compression garments
  5. Prosthetics or orthotics, available to restore or enhance normal lifestyle function

Venous ulcers are treated somewhat differently with compression of the leg to minimize edema or swelling. Compression treatments may include wearing compression stockings, multilayer compression wraps, or wrapping an ACE bandage or dressing from the toes or foot to the area below the knee. The type of compression treatment prescribed is determined by the physician based on the characteristics of the ulcer base and amount of drainage from the ulcer.

The type of dressing prescribed for ulcers is determined by the type of ulcer and the appearance at the base of the ulcer. Types of dressings include:

  1. Moist to moist dressings
  2. Hydrogels/hydrocolloids
  3. Alginate dressings
  4. Collagen wound dressings
  5. Debriding agents
  6. Antimicrobial dressings
  7. Composite dressings
  8. Synthetic skin substitutes
  9. Growth factor ointment

Treatments of arterial ulcer vary, depending on the severity of the arterial disease. Non-invasive vascular tests provide the physician with the diagnostic tools to assess the potential for wound healing. Depending on the patient’s condition, the physician may recommend invasive testing, endovascular therapy or bypass surgery to restore circulation to the affected leg. The goals for arterial ulcer treatment include:

  1. Providing adequate protection of the surface of the skin
  2. Preventing new ulcers
  3. Removing contact irritation to the existing ulcer
  4. Monitoring for signs and symptoms of infection that may involve the soft tissues or bone.

Neurotrophic ulcers are treated are treated by avoiding pressure and weight-bearing on the affected leg until the ulcer has started to heal. Regular debridement (the removal of infected tissue) is usually necessary before a neurotrophic ulcer can heal. Frequently, special shoes or orthotic devices must be worn.

Wound Care at Home

As stated in the aforementioned section, a proper wound care program including home wound care by the patient is critical to the healing process. Patients should be given careful instructions to care for their wounds at home. These instructions include:

  1. Keeping the wound clean
  2. Changing the dressing as directed
  3. Taking prescribed medications as directed
  4. Applying topical growth factors as directed
  5. Drinking plenty of fluids
  6. Following a healthy diet, as recommended, including plenty of fruits and vegetables
  7. Exercising regularly, as directed by a physician
  8. Wearing appropriate shoes
  9. Wearing compression wraps, if appropriate, as directed

The treatment of all ulcers begins with careful skin and foot care. Inspection of the feet and skin by the patient is very important, especially for people with diabetes. Detecting and treating foot and skin sores early can help prevent infection and prevent the sore from becoming worse. Here are some guidelines:

  1. Gently wash the affected area on your leg and your feet every day with mild soap and lukewarm water. Washing helps loosen and remove dead skin and other debris or drainage from the ulcer. Gently and thoroughly dry your skin and feet, including between the toes. Do not rub your skin or area between the toes.
  2. Every day, examine your legs as well as the tops and bottoms of your feet and the areas between your toes. Look for any blisters, cuts, cracks, scratches or other sores. Also check for redness, increased warmth, ingrown toenails, corns and calluses. Use a mirror to view the leg or foot if necessary, or have a family member look at the area for you.
  3. Once or twice a day, apply a lanolin-based cream to your legs and soles and top of your feet to prevent dry skin and cracking. Do not apply lotion between your toes or on areas where there is an open sore or cut. If the skin is extremely dry, use the moisturizing cream more often.
  4. Care for your toenails regularly. Cut your toenails after bathing, when they are soft. Cut toenails straight across and smooth with an emery board.
  5. Do not self-treat corns, calluses or other foot problems. Go to a podiatrist to treat these conditions.
  6. Don’t wait to treat a minor foot or skin problem. Follow your physcian’s guidelines.
  7. Ask your physician about using a growth factor ointment on the open sore area.

How can ulcers be prevented? Controlling risk factors can help you prevent ulcers from developing or becoming worse. Here are some ways to reduce your risk factors:

  1. Quit smoking
  2. Manage your blood pressure
  3. Control your blood cholesterol and triglyceride levels by making dietary changes and taking medications as prescribed
  4. Limit your intake of sodium (salt)
  5. Manage your diabetes and other health conditions, if applicable
  6. Exercise — start a walking program after speaking with your physcian
  7. Lose weight if you are overweight
  8. Ask your physcian about aspirin therapy to prevent blood clots