Leg Ulcer Is Not Only Focal Skin Necrosis but Also Edema and Inflammation of Peri-ulcer Areas, Dilatation of Lymphatics and Enlargement of Lymph Nodes

Background. Venous, arterial or posttraumatic leg ulcers lack dermis that is replaced by granulation tissue. The area of non-healing ulcers ranges between 3 and 15 cm. The question arises whether this seen with naked eye are the only 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 and can be shown. Although ulcer surface can be covered by epidermis, the changes in deep tissues persist  and are responsible for recurrencies or fibrosis.

Aim. To study ulcer skin adjacent tissues water content, stiffness, capillary blood flow, lymphatic drainage, lymphatics and inguinal lymph nodes.

Material and methods. In the skin surrounding  leg “venous” ulcers (5,10,15 cm from  ulcer core) water content (%), stiffness (in Newtons), blood capillary flow (point Doppler flow velocity), lymphatic drainage (near infra-red indocyanine green fluorescence, ICG %), lymphoscintigraphy and thermography visualized areas were measured.

Results. At 5 cm from ulcer core water concentration was in the range of 56 to 67% (control 35%), stiffness caused by fluid excess was over 1 N (control 0.06), blood capillary flow ranged between 5 and 20mV (control over 50mV). There was no immediate tissue fluid/lymph drainage. ICG lymphography showed leg lymph bypassing the ulcer region. Dilated lymphatics and enlarged inguinal nodes were observed. Thermography 34-38C areas were seen at a radius of 15 cm.

Conclusions. Leg ulcer is focal skin necrosis, inflammation of skin and subcutis at far distance around of ulcer, reaction of draining lymphatics and nodes. Combined local and systemic therapy should be considered.