An Overview of Venous Leg Ulcers

Venous leg ulcers occur in 1–3% of the adult population and account for the majority of lower extremity ulcerations. As the obesity rate increases we can expect the prevalence of VLU’s to increase as well. As compression for VLU becomes a better acknowledged standard of care and with the multitude of user friendly compression products on the market effective compression is being applied more commonly in a variety of settings. One consequence we are seeing from this is that a larger percentage of the patients with VLU that are referred to the wound clinic are more complex and may have already failed routine compression. Frequently these patients need more customized levels of compression and may require adjunctive therapies to achieve healing.

When treating a patient with a venous leg ulcer it is important to remember that we are treating the sequelae of an underlying medical condition. In addition to evaluating the wound it is important to evaluate and treat the venous insufficiency. At the very least patients need to be educated regarding aggravating and alleviating factors as well as the long-term need for compression. Patients who are possible candidates should be referred for corrective venous procedures.

The classic VLU is seen in the edematous leg in the medial gaitor area. It is shallow with irregular borders and has a high amount of exudate. Although not pain free, pain is not usually a top complaint. While there are several different theories on the exact etiology of ulceration in the patient with venous insufficiency it is well accepted that edema must be controlled for healing to occur. With the application of compression edema is reduced and exudates minimized. Continued or new onset of moderate to high volume of exudates in the presence of controlled edema is frequently due to uncontrolled bioburden. Treatment with topical or systemic antimicrobials when indicated will usually reduce the level of exudate. Once a clean, moist wound base is established the ulcer should progress to healing.

Many of the hard to heal VLUs occur in people with mixed arterial and venous disease. As long as there is edema present they need to be treated with compression. However the presence of the arterial disease decreases the tolerance of compression. You must find the line between that is enough compression to reduce and control the edema but not so much compression that it interferes with an already reduced arterial flow. Initially these patients may need to be seen every 2 to 3 days for a gradual increase in compression to find their optimal level.

Venous insufficiency compounded by obesity and or lymphatic insufficiency is another scenario commonly found in the patient with the recalcitrant VLU. These patients frequently need more aggressive compression bandaging due to the increased girth of their limb. The presence of significant fibrosis also necessitates greater compression.

There is a great deal of recidivism seen in VLU. This results in many ulcers occurring in scar tissue which has reduced ability to repair. Even with correct compression many VLU seen in the wound clinic will not progress without more advanced interventions such as biologically active topicals, grafted tissue, or NPWT.

While it is becoming less common we do get patients that present to the clinic with ulcers that have been present for years. Even with a positive work up for venous insufficiency a biopsy should be done to rule out Marjolins ulcer. A Marjolins ulcer is a cutaneous squamous cell carcinoma that can arise in chronically inflamed skin. Another consideration in the long standing venous leg ulcer is underlying osteomyelitis. As this occurs less commonly in VLU than in DFU it can be easily overlooked.

A common pitfall in the clinic is to assume that all ulcers seen in the edematous leg are due to underlying venous disease. There will usually be improvement in the status of the wound when the edema is addressed since edema can impede healing in any type of ulcer. This improvement reinforces the clinical assumption that the wound is a venous ulcer. Frequently ulcer’s progress will stall. As a significant number of venous ulcers do not readily heal with compression alone adjunctive therapies are frequently started. If the underlying disease process is not venous insufficiency and has not been addressed the non-venous ulcer may continue to be recalcitrant to the efforts being made. While confirming venous insufficiency through photoplethysmography or Doppler studies early on in the treatment process does not rule out the presence of a concomitant disease process it will allow you to identify the edematous leg ulcer without a significant venous component much earlier.

Tere has worked as a Physical Therapist for 25 years in a range of settings including acute care, outpatient, long term care and home health. She has been focused on wound care since 1991. In 1999 Tere established the Archbold Center for Wound Management at Archbold Memorial Hospital in Thomasville GA and is still the clinical director. This past year the center has expanded to include Hyperbaric Medicine.
Tere is an active member of APTA and AAWC. She earned her CWS through AAWM in 2000. She has served on advisory boards and participated in focus groups for several companies in the wound care industries.
Tere also began lymphedema management in 1996 after completing training in Manual Lymph Drainage through the Vodder School in Walschee Austria. In 2002 she passed the Board Exam to become Certified as a Lymphedema Therapist through the Lymphology Association of North America.