Recognizing and Treating Venous Stasis Ulcers

Abstract and Introduction

Abstract

Venous ulcers, also referred to as venous stasis ulcers (VSUs), are the most common cause of ulcerations that affect the lower extremities. These types of ulcers are experienced by an estimated 1% of the U.S. population. The incidence of VSUs is most prevalent among the elderly population and is also ubiquitous in patients with a medical history of edema in the legs, long-standing varicose veins, or blood clots in either the superficial or the deep veins of the legs. VSUs generally occur in the lower extremities, especially along the medial distal ankle. In general, treatments for VSUs include compression therapy, local wound care and debridement, various types of wound dressings, antibiotics for infected wounds, the use of pharmacologic agents such as pentoxifylline, aspirin, calcium channel blockers, and topical corticosteroids when warranted, as well as surgery and other forms of adjunctive therapy.

Introduction

Venous ulcers, also referred to as venous stasis ulcers(VSUs), are perceived to be the most common cause of ulcerations affecting the lower extremities and can be severe and debilitating in nature.^[1–3] VSUs affect an estimated 1% of the U.S. population and are responsible for more than 80% of lower extremity ulcerations.^[1–3] Statistics also report that an estimated 2.5% of patients admitted to long-term care facilities have VSUs.^[4]

The probability of developing a VSU is directly proportional to increasing age, and its occurrence is also common in patient populations with a history of venous insufficiency.^[1–5] VSUs occur more frequently in the elderly patient population for several reasons, including calf muscle pump failure, immobility, chronic edema, and obesity.^[6] Ulceration is precipitated by decreased diffusion of oxygen to the skin and microvasculature damages.^[4,5] Moreover, the incidence is also greater among paraplegic patients owing to the fact that the calf muscles are immobile.^[4,5]

The healing rates associated with VSUs are often poor, and an estimated 50% of these types of ulcers are still open and unhealed for 9 months or longer.^[4,5] Therefore, increasing awareness about early recognition, clinical intervention, and patient compliance with therapy is critical to enhancing healing and positive patient outcomes. VSU recurrence rates are also disconcerting, as more than one-third of patients treated for VSUs experience four or more recurrences.^[4,5]

In the United States, VSUs have been estimated to contribute to significant direct and indirect healthcare and personal costs including loss of productivity, which accounts for more than 2 million days of absence from work and decreased quality of life. VSUs reportedly incur treatment costs of approximately $3 billion per year.^[1]

While most VSUs are caused by chronic venous insufficiency (CVI), it is imperative that clinicians rule out other underlying causes such as arterial, metabolic, neuropathic, hematologic, infectious, malignant, and inflammatory diseases.^[6] The differential diagnosis for the VSU may include ischemic ulceration, pyoderma gangrenosum, lymphedema, trauma, neuropathic ulceration, and cellulitis.^[7] Other possible causes of these types of ulcerations include inflammatory processes, resulting in leukocyte activation, endothelial damage, platelet aggregation, intracellular edema, arterial insufficiency, diabetic neuropathy, prolonged pressure, and chronic conditions such as rheumatoid arthritis, osteomyelitis, and vasculitis.^[1,4] VSUs are five to seven times more common than the arterial ulcers observed in those with peripheral artery disease.^[8]

VSUs are most commonly seen in patients with a history of leg swelling, varicose veins, or blood clots of the superficial or deep veins of the legs.^[7–9] Predisposing factors include diabetes mellitus, congestive heart failure, hypertension, and obesity. Diabetic patients with a VSU have a clinical profile and prognosis comparable to those of nondiabetic patients.^[8,10,11]

VSUs occur primarily on the lower extremity over bony prominences, especially along the medial distal ankle and mostly on the inner part of the leg, but the ulcers can occur anywhere on the lower leg and may affect one or both extremities.^[1–4,7]

Table 1. Types of Wound Dressings
Hydrofiber dressings Acetic acid dressings Silver-impregnated dressings, which have become more useful than topical silver sulfadiazine in treating VSUs Calcium alginate dressings Proteolytic enzyme agents Synthetic occlusive dressings Extracellular matrix dressings Bioengineered skin substitutes

VSU: venous stasis ulcer. Source: References 14, 16.

Table 2. Adjunctive Therapies for Treating VSUs
Drug	Indication
Pentoxifylline	An inhibitor of platelet aggregation, this agent is often used as an adjunct to compression therapy and is considered to be effective without compression therapy when suitable. It can be used as monotherapy when patients cannot tolerate compression therapy. It exerts its mechanism of action by decreasing platelet aggregation and thrombus formation. Dosing is usually 400 mg tid. Common adverse effects include nausea, vomiting, diarrhea, heartburn, and loss of appetite
Calcium channel blockers	Clinical studies show that this class of drugs is effective against large-vessel stiffness and venous hypertension
Aspirin	Aspirin therapy when combined with compression therapy can hasten ulcer healing and may decrease size of ulcer compared to using only compression therapy. Adding aspirin to compression therapy is typically recommended for treating VSUs unless contraindications are present
Topical corticosteroids	Topical corticosteroids such as betamethasone, triamcinolone, and fluocinolone are used to decrease erythema, inflammation, pruritus, and vesicle formation
Antibiotics	Recommended when there is a suspected wound-bed infection and cellulitis
Diuretics	Diuretics are prescribed for patients with other medical conditions, such as congestive heart failure, that exacerbate lower extremity edema