Venous stasis ulcer

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In medicine, venous stasis ulcers (varicose ulcer) are a form of leg ulcer due to venous insufficiency and are "skin breakdown or ulceration caused by varicose veins in which there is too much hydrostatic pressure in the superficial venous system of the leg. Venous hypertension leads to increased pressure in the capillary bed, transudation of fluid and proteins into the interstitial space, altering blood flow and supply of nutrients to the skin and subcutaneous tissues, and eventual ulceration."[1]

At any given time, the rate of adults with open ulcers is estimated to be 0.12% to 0.32%[2] with 1% of adults estimated to have ulcers at some point in their life[3].

Etiology

The most likely cause is lost efficiency of the valves in the deep veins of the leg increasing the pressure in the veins and thus decreasing the exchange of blood from arteries through the capillaries. It is not clear how often this is due to primary incompetence of the deep and/or perforating venous valves versus deep venous thrombosis.[4]

Treatment

Reviews by Clinical Evidence and others are available to guide treatment.[5][6]

Compression therapy

Compression bandages improve healing.[5] Non-elastic, ambulatory, below knee (BK) compression counters the impact of reflux on venous pump failure.[7] Compression therapy is used for venous leg ulcers and can decrease blood vessel diameter and pressure, which increases their effectiveness, preventing blood from flowing backwards.[8] Compression is also used [8][9] to increase release of inflammatory cytokines, lower the amount of fluid leaking from capillaries and therefore prevent swelling, and prevent clotting by decreasing activation of thrombin and increasing that of plasmin.[10]

It is not clear whether non-elastic systems are better than a multilayer elastic system.[5] Compression is applied using elastic bandages or boots specifically designed for the purpose.[8] Patients should wear as much compression as is comfortable. [11]

Intermittent pneumatic compression devices may be used, but it is not clear that they are superior to simple compression dressings.[12]

Type of dressing

Regarding types of high pressure bandages, (ankle pressure 35-40 mm Hg), an individual patient data meta-analysis concluded "four layer bandages heal faster, on average, than those of people treated with the short stretch bandage."[13] High pressure dressing are contraindicated in patients with significant peripheral arterial disease.

The type of dressing applied beneath the compression may or may not matter. A meta-analysis by the Cochrane Collaboration concluded the type of dressing does note matter, specially hydrogel[14] and hydocolloid are not better than simple low adherent dressings.[15][16] Another systematic review concluded that hydocolloid is better.[17] The optimal pressure for treating venous stasis ulcers according to one trial is below; in this trial the average ulcer size was 10 cm2 (diameter = 3 cm) and the average calf circumference was 40 cm:[18]

Pentoxifylline

A meta-analysis of randomized controlled trials by the Cochrane Collaboration found that "Pentoxifylline is an effective adjunct to compression bandaging for treating venous leg ulcers and may be effective in the absence of compression".[19]

Artificial skin

Artificial skin, made of collagen and cultured skin cells, is also used to cover venous ulcers and excrete growth factors to help them heal.[20] A meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded "Bilayer artificial skin, used in conjunction with compression bandaging, increases the chance of healing a venous ulcer compared with compression and a simple dressing".[21]

Surgical correction of superficial venous reflux

A randomized controlled trial found that surgery "reduces the recurrence of ulcers at four years and results in a greater proportion of ulcer free time".[22]

Antibiotics and antiseptics

Among antibiotics and antiseptics, cadexomer iodine (Iodosorb™) may increase healing rates.[23]

Other treatments

Iloprost, a synthetic analogue of prostacyclin PGI2 can improve healing according to a randomized controlled trial.[24] In this initial trial, healing rates at 90 days were 100% in the intervention group and 50% in the control group.

Prognosis

Among leg ulcers that are 13 cm2 in size (4 cm diameter), about half a year is needed to heal.[25]

Recurrence of leg ulcers may happen.[10][8] One study found that up to 48% of venous ulcers had recurred by the fifth year after healing.[8]

References

  1. Anonymous (2015), Venous stasis ulcer (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. Graham ID, Harrison MB, Nelson EA, Lorimer K, Fisher A (2003). "Prevalence of lower-limb ulceration: a systematic review of prevalence studies.". Adv Skin Wound Care 16 (6): 305-16. PMID 14652517.
  3. Briggs M, Nelson EA (2010). "Topical agents or dressings for pain in venous leg ulcers.". Cochrane Database Syst Rev 4: CD001177. DOI:10.1002/14651858.CD001177.pub2. PMID 20393931. Research Blogging.
  4. Train JS, Schanzer H, Peirce EC, Dan SJ, Mitty HA (1987). "Radiological evaluation of the chronic venous stasis syndrome.". JAMA 258 (7): 941-4. PMID 3613024.
  5. 5.0 5.1 5.2 Nelson EA, Cullum N, Jones J (2006). "Venous leg ulcers". Clinical evidence (15): 2607-26. PMID 16973096[e]
  6. * van Gent WB et al. (2010) Management of venous ulcer disease. BMJ 341 DOI:10.1136/bmj.c6045
  7. B. McDonagh, S. Sorenson, A. Cohen, T. Eaton, D.E. Huntley, M. Schul, C. Martin, C. Gray, P. Putterman, T. King, J.L. Harry, R.C. Guptan. Venous Stasis Ulcer. Retrieved on 2007-08-05.
  8. 8.0 8.1 8.2 8.3 8.4 Brem H, Kirsner RS, Falanga V (2004). "Protocol for the successful treatment of venous ulcers". Am. J. Surg. 188 (1A Suppl): 1-8. DOI:10.1016/S0002-9610(03)00284-8. PMID 15223495. Research Blogging.
  9. Taylor JE, Laity PR, Hicks J, et al (2005). "Extent of iron pick-up in deforoxamine-coupled polyurethane materials for therapy of chronic wounds". Biomaterials 26 (30): 6024-33. DOI:10.1016/j.biomaterials.2005.03.015. PMID 15885771. Research Blogging.
  10. 10.0 10.1 Snyder RJ (2005). "Treatment of nonhealing ulcers with allografts". Clin. Dermatol. 23 (4): 388–95. DOI:10.1016/j.clindermatol.2004.07.020. PMID 16023934. Research Blogging.
  11. Nelson EA, Harper DR, Prescott RJ, Gibson B, Brown D, Ruckley CV (2006). "Prevention of recurrence of venous ulceration: randomized controlled trial of class 2 and class 3 elastic compression". J. Vasc. Surg. 44 (4): 803-8. DOI:10.1016/j.jvs.2006.05.051. PMID 17012004. Research Blogging.
  12. Nelson EA, Hillman A, Thomas K (2014). "Intermittent pneumatic compression for treating venous leg ulcers.". Cochrane Database Syst Rev 5: CD001899. DOI:10.1002/14651858.CD001899.pub4. PMID 24820100. Research Blogging.
  13. O'Meara S, Tierney J, Cullum N, et al (2009). "Four layer bandage compared with short stretch bandage for venous leg ulcers: systematic review and meta-analysis of randomised controlled trials with data from individual patients". BMJ 338: b1344. PMID 19376798. PMC 2670366[e]
  14. Dumville JC, Stubbs N, Keogh SJ, Walker RM, Liu Z (2015). "Hydrogel dressings for treating pressure ulcers.". Cochrane Database Syst Rev 2: CD011226. DOI:10.1002/14651858.CD011226.pub2. PMID 25687578. Research Blogging.
  15. Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA (2006). "Dressings for healing venous leg ulcers". Cochrane database of systematic reviews (Online) 3: CD001103. DOI:10.1002/14651858.CD001103.pub2. PMID 16855958. Research Blogging.
  16. Palfreyman S, Nelson EA, Michaels JA (2007). "Dressings for venous leg ulcers: systematic review and meta-analysis". BMJ 335 (7613): 244. DOI:10.1136/bmj.39248.634977.AE. PMID 17631512. Research Blogging.
  17. Chaby G, Senet P, Vaneau M, et al (2007). "Dressings for acute and chronic wounds: a systematic review". Archives of dermatology 143 (10): 1297–304. DOI:10.1001/archderm.143.10.1297. PMID 17938344. Research Blogging.
  18. Milic DJ, Zivic SS, Bogdanovic DC, Jovanovic MM, Jankovic RJ, Milosevic ZD et al. (2010). "The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy.". J Vasc Surg 51 (3): 655-61. DOI:10.1016/j.jvs.2009.10.042. PMID 20045611. Research Blogging.
  19. Jull A, Arroll B, Parag V, Waters J (2007). "Pentoxifylline for treating venous leg ulcers". Cochrane database of systematic reviews (Online) (3): CD001733. DOI:10.1002/14651858.CD001733.pub2. PMID 17636683. Research Blogging.
  20. Mustoe T. 2005. Dermal ulcer healing: Advances in understanding. Presented at meeting: Tissue repair and ulcer/wound healing: molecular mechanisms, therapeutic targets and future directions. Paris, France, March 17-18, 2005. Available.
  21. Jones JE, Nelson EA (2007). "Skin grafting for venous leg ulcers". Cochrane database of systematic reviews (Online) (2): CD001737. DOI:10.1002/14651858.CD001737.pub3. PMID 17443510. Research Blogging.
  22. Gohel MS, Barwell JR, Taylor M, et al (2007). "Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial". BMJ 335 (7610): 83. DOI:10.1136/bmj.39216.542442.BE. PMID 17545185. Research Blogging.
  23. O'Meara S, Al-Kurdi D, Ologun Y, Ovington LG (2010). "Antibiotics and antiseptics for venous leg ulcers.". Cochrane Database Syst Rev (1): CD003557. DOI:10.1002/14651858.CD003557.pub3. PMID 20091548. Research Blogging.
  24. Ferrara F, Meli F, Raimondi F, et al (2007). "The treatment of venous leg ulcers: a new therapeutic use of iloprost". Ann. Surg. 246 (5): 860–5. DOI:10.1097/SLA.0b013e3180caa44c. PMID 17968180. Research Blogging.
  25. Brizzio E, Amsler F, Lun B, Blättler W (2010). "Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers.". J Vasc Surg 51 (2): 410-6. DOI:10.1016/j.jvs.2009.08.048. PMID 19879713. Research Blogging.