Ulcer - loss of area of epidermis and dermis to produce a defect even down to fat, muscle, tendons and bone
Erosion - loss of area of epidermis
| Characteristic | Venous Ulcers | Arterial Ulcers |
|---|---|---|
| Location | Typically found on the lower | Usually occur on the lower |
| leg, near the ankle. Medial | extremities, especially the | |
| malleolus | toes, heels, or lateral | |
| malleolus. | ||
| Etiology | Result from venous | Caused by poor arterial |
| insufficiency, often due to | blood supply, often due to | |
| Varicose veins or deep vein | atherosclerosis, embolism, | |
| thrombosis. | or thrombosis. | |
| Wound Appearance | Shallow, irregularly shaped | Deep, well-defined borders |
| with a weepy, exudative base. | and minimal exudate. | |
| Edema | Commonly associated with | Usually absent or minimal. |
| edema in the surrounding | ||
| area. | ||
| Pain | Often minimal or no pain. | Severe, constant pain, |
| especially when the limb is | ||
| elevated. | ||
| Skin Changes | May exhibit pigmentation, | Skin may be pale, cool, and |
| lipodermatosclerosis, and | shiny, with loss of hair, | |
| eczematous changes. | brittle nails, and muscle | |
| atrophy. | ||
| Wound Base | Typically granulating or | Often necrotic or pale, |
| fibrinous. | indicating tissue ischemia. | |
| Ulcer Shape | Irregular and often shallow. | Well-defined and deeper. |
| Pulses | Pulses are usually present. | Pulses may be diminished or |
| absent. | ||
| Dressings | Moist wound dressings are | Dry dressings are typically |
| often used to promote | used to protect the wound | |
| healing and manage exudate. | and surrounding tissue. | |
| Treatment | Compression therapy is the | Revascularization through |
| mainstay of treatment. | surgery or endovascular | |
| Wound debridement and | procedures is often | |
| wound care are essential. | necessary. |
Causes
Vascular 90% - both occur due to a lack of perfusion whether venous of arterial
- Venous 70%
- Arterial 10%
- Mixed 10%
Other 10%
Rarer causes
- Neuropathic - peripheral neuropathy ← Diabetes Mellitus
- Inflammatory - pyoderma gangrenosum
- Malignant - SCC, BCC, lymphoma
- Vascular - vasculitis
- Iatrogenic - pressure sores, drugs (warfarin necrosis)
- Infection
- Metabolic
- Traumatic - burns
Risk Factors
Venous - impaired blood flow in the veins (typically of the legs)
-
middle aged elderly women
-
valvular incompetence
-
previous damage to venous system
-
Obesity, immobility → poor muscle contraction → venous pooling
-
high BP
-
multiple pregnancies
Arterial - poor arterial blood supply to affected area, usually very distal
- associated with peripheral vascular disease
- smoking
- hyperlipidemia
- hypercholesterolemia
Signs
Venous - smooth sloping border, superficial, ill defined border
- Venous flare
- Lipodermatosclerosis
- Varicose veins
- Varicose eczema
- Atrophie blanche
Arterial - punched out painful ulcer, dry skin,
Diagnostic Tests
- skin biopsy if cannot determine cause or exclude skin malignancy
- Ankle brachial pressure index
- depends on suspected underlying cause
Management
- Treat the underlying cause
- Venous ulcer - compression stocking/bandage
- Pentoxifylline - increases microvascular blood flow