Inflamed tissues around the leg ulcer 3-times larger than ulcer’s bed-evaluation of changes in remote tissues and lymph nodes

Background. Venous, arterial or posttraumatic leg ulcers lack dermis that should be replaced by granulation tissue. The area of non-healing ulcers ranges between 3 sq cm and 15 sq cm. The question arises whether ulcer seen with naked eye is the only site of tissue changes. Recent methods of visualization of the interstitial space as indocyanine green fluorescence and isotopic lymphography enabled showing changes in the ulcer adjacent and remote tissues.  Sites of accumulation of edema fluid and inflammation can be defined. Changes in the draining lymphatic vessels can be shown. Although ulcer surface can be covered by epidermis, the changes in deep tissues persist and are responsible for exacerbation and fibrosis. Aim. To study ulcer skin adjacent tissues lymphatic drainage, lymphatics and inguinal lymph nodes. Material and methods. In the skin surrounding leg “venous” ulcers (5,10,15 cm from  ulcer core) lymphatic drainage (near infra-red indocyanine green fluorescence, ICG %), lymphoscintigraphy visualized areas were shown. Results. There was no immediate tissue fluid/lymph ICG drainage from the ulcer edge. Slowly ICG showed leg lymph bypassing the ulcer region forming large stained areas below and above the ulcer. Confluent spots of ICG were detected above the knee and in inguinal skin fold. In some cases, dilated lymphatics and enlarged inguinal nodes were observed. Conclusions. Leg ulcer is focal skin necrosis, inflammation of skin and subcutis also at a distance from ulcer, as well as reaction of the draining lymphatics and nodes. Limiting attention to treatment of the ulcer only without following the changes in the whole limb cannot bring about expected effects. Combined local and systemic therapy should be considered, depending of the extent of changes.