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BASICS

  • Venous insufficiency: venous system dysfunction causing inadequate venous return.
  • Chronic venous insufficiency manifests with edema, hyperpigmentation, stasis dermatitis, and venous ulcers.
  • Venous ulcers are irregular, shallow skin defects over bony prominences, present >30 days, often painful if infected.
  • Significant healthcare burden with annual treatment costs of $2.5-3.5 billion in the U.S.

EPIDEMIOLOGY

  • Venous ulcers cause ~80% of leg ulcers; arterial disease accounts for 10-25%.
  • Incidence: 18/100,000 persons; more common in women.

  • 20,000 new cases yearly in the U.S.

  • Prevalence ~1% in adults; up to 4% in adults ≥80 years.
  • Recurrence rate ~70% within 5 years.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Venous hypertension due to obstruction, incompetent valves, or muscle pump failure.
  • Increased venous pressure leads to capillary leakage, RBC extravasation, tissue ischemia.
  • Leukocyte aggregation causes local inflammation and chronic skin damage.
  • Genetic factors: autosomal dominant with variable penetrance; FOXC2 gene implicated.

RISK FACTORS

  • Age >55 years, obesity, prior leg injury.
  • Congestive heart failure.
  • History of deep vein thrombosis (DVT).
  • Impaired calf muscle pump function.
  • Prior varicose vein surgery or ulcers.
  • Smoking, prolonged standing, pregnancy.

GENERAL PREVENTION

  • Use compression stockings (20-30 mm Hg) after DVT for at least 2 years.
  • Treat underlying venous disease.
  • Exercise to improve calf muscle pump.
  • Avoid topical triple antibiotic ointments containing neomycin.

DIAGNOSIS

History

  • Duration of wound, pain, history of trauma or DVT.
  • Symptoms: cramping, pruritus, throbbing, pain improving with leg elevation.
  • Past treatments attempted.

Physical Exam

  • Pitting edema, hyperpigmentation (hemosiderin staining), stasis dermatitis.
  • Atrophie blanche, lipodermatosclerosis.
  • Palpate pulses and assess for signs of arterial disease.
  • Measure wound size, depth; assess for necrotic tissue or infection.
  • Measure ankle and calf girth for edema monitoring.

DIFFERENTIAL DIAGNOSIS

  • Arterial insufficiency ulcers.
  • Neuropathic ulcers.
  • Lymphedema.
  • Cellulitis.
  • Malignancy (Marjolin ulcer).
  • Vasculitic ulcers.
  • Other rare infections or dermatologic diseases.

DIAGNOSTIC TESTS & INTERPRETATION

  • Ankle-brachial index (ABI): <0.8 contraindicates compression therapy; >1.3 suggests arterial calcification.
  • Duplex ultrasonography to evaluate venous reflux and obstruction.
  • Biopsy ulcers with atypical features or failure to heal.
  • Labs: fasting glucose, Factor V Leiden mutation if indicated.

TREATMENT

General Measures

  • Compression therapy: standard of care; elastic and inelastic options.
  • Leg elevation 3-4 times/day for 30 minutes.
  • Wound dressings to protect peri-ulcer skin and promote healing.
  • Barrier creams to prevent maceration.
  • Exercise to activate calf muscle pump.

Medications

  • Micronized purified flavonoid fraction recommended to aid healing.
  • Oral antibiotics only if infection suspected.
  • Avoid routine antibiotics for uninfected ulcers.
  • Treat cellulitis promptly if present.

Surgery and Other Therapies

  • Surgical options (sclerotherapy, endovenous ablation, vascular surgery) reserved for refractory ulcers.
  • Early endovenous ablation improves healing time.
  • Negative pressure wound therapy and platelet-rich plasma show promise.
  • Debridement (sharp, enzymatic, mechanical, autolytic) for necrotic tissue.
  • Skin grafting in selected cases.

ISSUES FOR REFERRAL

  • Refer to wound care specialists for complex or non-healing ulcers (>3 months, >10 cm).
  • Vascular surgery referral if ABI <0.8 or recurrent ulcers.
  • Certified lymphedema therapist for patients with significant edema.

ONGOING CARE

  • Monitor wound size; expect ~10% size reduction biweekly.
  • Transition to compression stockings when ulcers near healing.
  • Weight loss and low-sodium diet if BMI elevated.

PATIENT EDUCATION

  • Emphasize proper wound care and hygiene.
  • Tobacco cessation.
  • Importance of compression therapy compliance.
  • Recognize signs of infection.

PROGNOSIS

  • Healing depends on ulcer duration, size, arterial disease, age, and BMI.
  • Recurrence common.
  • Venous ulcers cause significant morbidity and reduced quality of life.

COMPLICATIONS

  • Chronic pain and infection.
  • Malnutrition and dehydration.
  • Gingival/tooth loss (if oral involvement).
  • Deep infections extending to neck or systemic spread.

REFERENCES

  1. Bonkemeyer Millan S, Gan R, Townsend PE. Venous ulcers: diagnosis and treatment. Am Fam Physician. 2019;100(5):298-305.
  2. Ren SY, Liu YS, Zhu GJ, et al. Strategies and challenges in the treatment of chronic venous leg ulcers. World J Clin Cases. 2020;8(21):5070-5085.
  3. Elsharnoby AM, El-Barbary AH, Eldeeb AE, et al. Resistant chronic venous leg ulcers: efficacy of adjuvant systemic hyperbaric oxygen therapy versus venous intervention alone. Int J Low Extrem Wounds. 2022.

ICD10

  • I87.2 Chronic venous insufficiency (CVI)
  • I83.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site
  • I89.0 Lymphedema, not elsewhere classified

Clinical Pearls

  • Diagnosis is primarily clinical; use ABI and duplex ultrasound if unclear.
  • Compression therapy is first-line and contraindicated if ABI <0.8.
  • Avoid neomycin-containing topical antibiotics.
  • Early vascular referral improves outcomes for severe or recurrent ulcers.