Venous ulcers

doi:10.1016/j.clindermatol.2006.09.004

Clinics in Dermatology

Volume 25, Issue 1, January–February 2007, Pages 121-130

https://doi.org/10.1016/j.clindermatol.2006.09.004 Get rights and content

Abstract

Chronic venous ulceration is a common and important medical problem, which causes significant morbidity. Venous ulcers are expensive to treat, have substantial economic effects in terms of days of work lost, and adversely impact patient's quality of life. History and clinical findings are helpful in making the diagnosis of venous ulceration, but additional diagnostic testing is helpful in confirming the diagnosis and excluding arterial disease. The objectives of venous ulcer management include healing of the ulcer, prevention of recurrence, and improvement of edema. Compression is the cornerstone of venous ulcer therapy. Adjunctive modalities such as biologic skin substitutes, dressings, debridement, surgical intervention, and drugs may also facilitate the healing process.

Section snippets

Epidemiology

Chronic venous disease, including chronic venous insufficiency and chronic venous ulceration, is a common and important medical problem that causes significant morbidity. Venous ulcers are expensive to treat and adversely impact patients' quality of life.1, 2 Studies have shown that an estimated 5% to 8% of the world population suffers from venous disease and approximately 1% develops venous ulcers.2, 3 In the United States alone, 5 million individuals have venous disease and approximately

Pathophysiology

The venous system of the lower extremity comprises 3 components: the superficial veins, perforator veins, and the deep veins. The deep veins lay within the muscles of the lower extremity, whereas the superficial veins lie above the fascia overlying these muscles. The perforator or communicating veins connects the superficial and deep vein systems. The superficial veins are low-pressure systems, whereas the deep veins are high-pressure systems. All 3 venous systems have 1-way valves, which only

Clinical features of venous ulcers

Patients with venous ulcers may report having swelling of the lower extremities and an aching of the legs, which is worse at the end of the day and improves with elevation. These patients may also have a history of coagulopathies, deep venous thrombosis, trauma, or surgery to the leg.³⁹ Venous insufficiency and venous ulcers has been described with the risk factors of preponderance of men, advancing age, phlebitis, trauma to the legs, congestive heart failure, family history of leg ulcers,

Management

The objectives of venous ulcer management include healing of the ulcer, prevention of recurrence, and improvement of edema.⁴⁹ To accomplish these goals, compression is used as the mainstay of therapy. Leg elevation is helpful but often not practical in reducing edema. Compression therapy has been shown to increase ulcer healing vs no compression.⁵⁰ Compression therapy counteracts venous hypertension by facilitating venous return toward the heart, improving venous pump function and lymphatic

References (72)

T. Phillips et al.
A study of the impact of leg ulcers on quality of life: financial, social and psychological implications
J Am Acad Dermatol
(1994)
D. Bergqvist et al.
Chronic leg ulcers: the impact of venous disease
J Vasc Surg
(1999)
R.G. De Palma et al.
Venous ulceration: a cross-over study from nonoperative to operative treatment
J Vasc Surg
(1996)
J.V. White et al.
Venous outflow of the leg: anatomy and physiologic mechanism of the plantar venous plexus
J Vasc Surg
(1996)
V. Falanga et al.
The trap hypothesis of venous ulceration
Lancet
(1993)
N. Browse et al.
The cause of venous ulceration
Lancet
(1982)
A.L. Claudy et al.
Detection of undergraded fibrin and tumor necrosis factor alpha in venous ulcers
J Am Acad Dermatol
(1991)
M.S. Gohel et al.
Risk factors for delayed healing and recurrence of chronic venous leg ulcers: an analysis of 1324 legs
Eur J Vasc Endovasc Surg
(2005)
A. Stanley et al.
Senescence and the healing rates of venous ulcers
J Vasc Surg
(2001)
J.H. Chen et al.
Loss of proliferate capacity and induction of senescence in oxidatively stressed human fibroblasts
J Biol Chem
(2004)

O. Nelzen et al.

Leg ulcer etiology—a cross sectional population study

J Vasc Surg

(1991)

T.J. Phillips et al.

Leg ulcers

J Am Acad Dermatol

(1991)

Barwell

Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomized controlled trial

Lancet

(2004)

S.G. Darke et al.

Venous ulceration and saphenous ligation

Eur J Vasc Surg

(1992)

C. Ruckley

Socioeconomic impact of chronic venous insufficiency and leg ulcers

Angiology

(1997)

P. Vanhoutte et al.

The demographics of venous disease of the lower limbs

Angiology

(1997)

M. Callam et al.

Chronic ulceration of the leg: extent of the problem and provision of care

Br J Med

(1985)

L. Abbade et al.

Venous ulcer; epidemiology, physiopathology, diagnosis and treatment

Int J Dermatol

(2005)

G.S. Lazarus et al.

Definitions and guidelines for assessment of wounds and evaluation of healing

Arch Dermatol

(1994)

K.J. Harkiss

Cost analysis of dressing materials used in venous leg ulcers

J Pharm

(1985)

J.W. Olin et al.

Medical cost of treating venous stasis ulcer: evidence from a retrospective cohort study

Vasc Med

(1999)

R.A. Weiss et al.

The bulletin of the North American Society of Phlebology. Insurance advisory committee report

J Dermatol Surg Oncol

(1992)

T.E. Scott et al.

Risk factors for chronic venous insufficiency: a dual case control study

J Vasc Surg

(1995)

I.C. Valencia et al.

Chronic venous insufficiency and venous leg ulceration

J Am Acad Dermatol

(2001)

M.J. Callam

Epidemiology of varicose veins

Br J Surg

(1994)

N.L. Browse et al.

Physiology and functional anatomy

V. Falanga

Venous ulceration

J Dermatol Surg Oncol

(1993)

V. Falanga et al.

Pericapillary fibrin cuffs in venous ulceration

J Dermatol Surg Oncol

(1992)

H.A.M. Neumann et al.

Transcutaneous oxygen tension in chronic venous insufficiency syndrome

Vasa

(1984)

H.A.M. Neumann et al.

Transcutaneous oxygen tension in patients with and without pericapillary fibrin cuffs in chronic venous insufficiency, porphyria cutanea tarda, and non venous leg ulcers

Vasa

(1996)

J. Pardes et al.

Skin capillaries surrounding chronic venous ulcers demonstrate smooth muscle hyperplasia and increased laminin type IV collagen

J Invest Dermatol

(1990)

V. Falanga

Chronic wounds: pathophysiologic and experimental considerations

Prog Dermatol

(1992)

P. Coleridge-Smith et al.

Causes of venous ulceration: a new hypothesis?

Br J Med

(1988)

H. Scott et al.

Histologic study of white blood cells and their association with lipodermatosclerosis and venous ulceration

Br J Surg

(1991)

P. Thomas et al.

White cell accumulation in dependent legs of patients with venous hypertension: a possible mechanism for trophic changes in the skin

Br J Med

(1988)

H. Higley et al.

Immunocytochemical analysis of growth factor and growth factor response cells in chronic venous stasis ulcers

Wounds

(1992)

Cited by (106)

Circular RNA Signatures of Human Healing and Nonhealing Wounds
2022, Journal of Investigative Dermatology
Citation Excerpt :
Venous ulcers (VUs) are a type of chronic nonhealing wounds occurring mainly in patients with chronic venous disease and venous hypertension (Bergan et al., 2006). It is estimated that 5‒8% of the world population suffers from venous disease and that 20% of these patients develop VUs (Etufugh and Phillips, 2007). Owing to the complex wound environment, many patients fail to respond to the therapy.
Venous ulcers (VUs) have complex and obscure pathogenicity, and effective VU therapies are still lacking. Circular RNAs (circRNAs) have emerged as powerful gene regulators with important roles in health and disease. In this study, we used paired total RNA and small RNA sequencing to profile circRNAs, protein-coding mRNAs, and microRNAs expression in a unique collection of clinical samples: healthy skin and acute wounds at inflammatory and proliferative phases and wound-edge VU biopsies. We unravel a dynamically changed expression pattern of circRNAs during human skin repair and their abnormal expression signature in VU, which are presented as a searchable web resource (www.xulandenlab.com/humanwounds-circrna). We analyzed the coexpression relationship between the circRNAs and mRNAs with weighted correlation network analysis and constructed circRNA‒mRNA‒microRNA networks. This allowed us to expose the regulatory networks specific to the inflammatory and proliferative phases of wound repair and VU, the biological processes the circRNAs may regulate, and the circRNAs that could sponge microRNAs in human wounds. Importantly, we found that hsa-CHST15_0003 and hsa-TNFRSF21_0001, two circRNAs upregulated in VU, hampered epidermal keratinocyte migration while promoting proliferation by modulating gene networks underpinning these cellular processes. This study paves the way to decipher the functional significance of circRNAs in tissue repair.
Nutrition and cutaneous wound healing
2022, Clinics in Dermatology
Citation Excerpt :
Patients having larger cutaneous wounds with high amounts of exudate are particularly prone to protein deficiency. Proteins are required for the maintenance of oncotic pressure within the intravascular compartment, particularly in patients with venous leg ulcers, where peripheral edema or associated lymphedema can delay wound healing.34,35 A prospective study found a higher prevalence of protein deficiency among ambulatory outpatients with leg ulcers (27%) than in those without (2%), and 55% of the malnourished patients also had a concomitant inflammatory syndrome, as measured by C-reactive protein.
Wound healing is a complex and energy-demanding process. The relationship between nutrition and wound healing has been recognized for many centuries. Several studies have indicated that nutritional deficiencies are more prevalent among patients with chronic wounds. Malnutrition may alter the inflammatory response, collagen synthesis, and wound tensile strength, all of which are crucial for wound healing. Although the specific role of nutrition and supplementation in wound care remains uncertain, it is necessary to identify and correct nutritional imbalances to avoid any potential deterioration of the healing process. It is also important to recognize the differences in pathophysiology between acute and chronic wounds. A burn, surgical, or a traumatic wound is different from a diabetic foot ulcer, which is different from a pressure ulcer. Chronic wounds are more prevalent in the aging population, and patients often have underlying comorbidities, such as diabetes mellitus, peripheral vascular disease, connective tissue disease, or other systemic illnesses that may alter energy metabolism and contribute to impaired healing. Management approaches to acute wound care may not apply universally to chronic wounds. In this review, we discuss the available data and possible roles for nutrition in wound healing.
Trends of hospital-based surgery for varicose veins in the elderly
2021, Journal of Vascular Surgery: Venous and Lymphatic Disorders
The treatment of varicose veins has shifted during the past decade to the office setting. Although recent studies have demonstrated the safety of venous ablation for the elderly in the office, a paucity of data is available on the contemporary outcomes of surgery for varicose veins in the operating room. The present study analyzed the trends and outcomes of varicose vein surgery in the elderly using a large national database.
The American College of Surgeons National Surgical Quality Initiative Program database (2005-2017) was reviewed. Patients undergoing vein ablation or open surgery (ie, high ligation, stripping, phlebectomy) for venous insufficiency were identified using Current Procedural Terminology codes and the principal diagnosis. The patients were stratified into 3 age groups <65, 65 to 79, and ≥80 years. The preoperative and operative characteristics and outcomes were compared. Logistic regression was performed to identify the risk factors associated with any adverse event, defined as any morbidity or mortality.
A total of 48,615 venous surgeries had been performed, with 9177 (18.9%) performed in patients aged 65 to 79 years and 1180 (2.4%) in patients aged ≥80 years. The proportion of patients in the 65- to 79-age group had steadily increased during the study period from 12.8% in 2005 to 22.3% in 2017 (P < .01). The proportion of patients aged ≥80 years had remained stable (P = .23). Patients aged ≥80 years had significantly more comorbidities, were more likely to have undergone vein ablation alone (P < .01), were more likely to be treated for ulceration (P < .01) and less likely to have received general anesthesia (P < .01) compared with the younger age groups. Overall morbidity increased significantly with increased age group (P < .01) but remained low (2.5%). Mortality was very low (0.02%) and not significantly different among the age groups. The factors independently associated with any adverse event were dialysis (odds ratio [OR], 7.12; 95% confidence interval [CI], 3.3-15.6), American Society of Anesthesiologists classification per unit increase (OR, 1.2; 95% CI, 1.02-1.3), use of general anesthesia (OR, 1.2; 95% CI, 1.0-1.4), and combined venous ablation and open procedures compared with venous ablation alone (OR, 1.3; 95% CI, 1.0-1.5). However, age was not associated with adverse events (OR, 1.0; 95% CI, 1.0-1.0).
Varicose vein surgery is safe for all age groups and is being increasingly offered to the elderly. High-risk patients might benefit from the avoidance of hybrid procedures and general anesthesia when possible to minimize the occurrence of adverse events. Conservative measures should be exhausted before surgery for the dialysis population.
Circulatory Disorders
2020, Neale’s Disorders of the Foot and Ankle
Application of plasma to humans (blood coagulation and regenerative medicine)
2018, Plasma Medical Science
Association of Venous Leg Ulcers With Ankle Range of Motion in People Attending Chiropractic Mobile Clinics in the Dominican Republic
2017, Journal of Chiropractic Medicine
Citation Excerpt :
All participants from the age of 9 years were invited to participate because it has been reported that venous disease can be found even in adolescents.19 Power analysis calculation for estimating prevalence in observational studies revealed that n = 1056 patients should be recruited20 for a study aimed to estimate the prevalence with a margin of error d = 0.006 and predefined ulcer prevalence equal to p = 0.01, as reported in other studies.12,14,21 Based on past experience, between 1000 and 1100 patients were typically seen on these outreaches, and so this was a feasible number of patients that could be expected during the outreach.
The goal of the study was to determine if there was an association between chronic venous disorders (CVDs), particularly venous leg ulcers, and ankle range of motion (ROM) in the Dominican Republic.
Chronic venous disorders were classified using the clinical manifestations portion (C) of the CEAP (clinical manifestations, etiology, anatomy, pathophysiology) method. The legs of participants attending mobile chiropractic clinics in rural, low-income areas in the Dominican Republic were assessed for clinical signs of CVD and venous ulcers. Ankle ROM was then measured, and photographs of the legs were taken. The 6 clinical stages of CVD were divided into 3 groups: normal legs (normal), no ulcer CVD, and ulcer CVD (healed and active). Multiple linear regression of ankle ROM against CVD grouping was used to test the association.
Eight of the 837 patients for whom CVD classification was obtained had venous ulcers (healed or active) on at least 1 leg. About 30% relative reduction in ROM (ankle dorsiflexion plus plantar flexion) was observed between the ulcer group and the normal group. Regression analysis comparing legs with ulcers to healthy legs (normal), adjusted for age, gender, indicator for obesity, and previous leg trauma, revealed a significant decrease of approximately 14° (P = .0007) in ankle ROM. Age was also found to be strongly significant in the regression analysis, 1 year of aging was associated with a decrease of 0.16° (P < .0001) in ankle ROM (approximately 1.6° in 10 years).
A significant decrease was observed in ankle ROM for participants with active and healed leg venous ulcers compared with those without ulcers. There appeared to be an association between venous leg ulcers and ankle ROM in this sample.

View all citing articles on Scopus

View full text

Venous ulcers

Abstract

Section snippets

Epidemiology

Pathophysiology

Clinical features of venous ulcers

Management

J Am Acad Dermatol

J Vasc Surg

J Vasc Surg

J Vasc Surg

Lancet

Lancet

J Am Acad Dermatol

Eur J Vasc Endovasc Surg

J Vasc Surg

J Biol Chem

J Vasc Surg

J Am Acad Dermatol

Lancet

Eur J Vasc Surg

Socioeconomic impact of chronic venous insufficiency and leg ulcers

Angiology

The demographics of venous disease of the lower limbs

Angiology

Chronic ulceration of the leg: extent of the problem and provision of care

Br J Med

Venous ulcer; epidemiology, physiopathology, diagnosis and treatment

Int J Dermatol

Definitions and guidelines for assessment of wounds and evaluation of healing

Arch Dermatol

Cost analysis of dressing materials used in venous leg ulcers

J Pharm

Medical cost of treating venous stasis ulcer: evidence from a retrospective cohort study

Vasc Med

The bulletin of the North American Society of Phlebology. Insurance advisory committee report

J Dermatol Surg Oncol

Risk factors for chronic venous insufficiency: a dual case control study

J Vasc Surg

Chronic venous insufficiency and venous leg ulceration

J Am Acad Dermatol

Epidemiology of varicose veins

Br J Surg

Physiology and functional anatomy

Venous ulceration

J Dermatol Surg Oncol

Pericapillary fibrin cuffs in venous ulceration

J Dermatol Surg Oncol

Transcutaneous oxygen tension in chronic venous insufficiency syndrome

Vasa

Transcutaneous oxygen tension in patients with and without pericapillary fibrin cuffs in chronic venous insufficiency, porphyria cutanea tarda, and non venous leg ulcers

Vasa

Skin capillaries surrounding chronic venous ulcers demonstrate smooth muscle hyperplasia and increased laminin type IV collagen

J Invest Dermatol

Chronic wounds: pathophysiologic and experimental considerations

Prog Dermatol

Causes of venous ulceration: a new hypothesis?

Br J Med

Histologic study of white blood cells and their association with lipodermatosclerosis and venous ulceration

Br J Surg

White cell accumulation in dependent legs of patients with venous hypertension: a possible mechanism for trophic changes in the skin

Br J Med

Immunocytochemical analysis of growth factor and growth factor response cells in chronic venous stasis ulcers

Wounds