Synonyms and Keywords
Chronic venous insufficiency (CVI).
What are Venous Stasis Ulcers?
A venous stasis ulcer is a leg wound that does not heal because of poor blood flow in the veins. It’s consequence of venous stasis, a disease of the leg veins in which the one-way valves inside the veins that help the blood flow from the leg back to the heart are weak and do not work correctly; some people are even born without these valves. Valve problems cause the blood to stay in the leg veins under lots of pressure, so when a wound happens from a hit or scratch, it does not heal as it usually would. Instead, it get larger from the pressure and may become infected (an ulcer).
Because of gravity that pushes the swelling and damage to the lower extremities, venous stasis ulcers are commonly spotted below the knee, primarily on the inner part of the leg, just above the ankle. They are typically red in color, sometimes covered with yellow fibrous tissue. If infected, there can be a green or yellow discharge. The sore itself tends to have an irregular shape. The ulceration can occur in one or both legs, sometimes more than one ulcer simultaneously.
Venous stasis ulcers that have lasted less than one year almost always close completely. Those present for long than a year may not close completely, but they do get smaller in size. The process of healing will take many months — and slower if you have blockages in your arteries or bone infection.
A potentially very painful condition, venous stasis ulcers are estimated to affect 500,000-600,000 people in the United State every year. The disorder is by far the most common type of leg ulcer seen, accounting for the loss 2 million working days and incurs treatment costs of near $3 billion dollars annually in the country.
What Causes Venous Stasis Ulcers?
A poor functioning venous system, where the veins of the legs are not properly pumping blood back to the heart, is the main reason for venous stasis ulcers. As blood becomes backlogged, the chronic swelling from the accumulation eventually weakens and damages the skin.
Weak valves in the vein walls can be hereditary, as well as the result of vein disease such as a blood clot in the leg. Trauma to the lower leg is another leading source of venous stasis ulceration. Inflammatory diseases such as lupus, vasculitis, scleroderma, or other joint-affecting afflictions can weaken the venous system and diminish skin texture which may then lead to venous stasis ulcers.
Other factors include obesity, being older, smoking, and pregnancy. If you’re not physically active, or have a history of standing, sitting, or lying in one position too long, it may precipitate the formation of a venous ulcer due to poor circulation of blood.
Who Gets Venous Stasis Ulcers?
Venous stasis ulcers account for 80-90% of all leg ulcers reported. The condition is common in patients with varicose veins (swollen veins filled with an abnormal collection of blood), a history of feet/leg swelling or blood clots in either the superficial or deep veins of the legs. Paraplegics may also develop these types of ulcers from the lack of blood-pumping ability in their calf muscles.
Incidence of venous stasis ulcer also rises substantially with age, peaking with women ages 40 to 49, and men of 70-79 years.
A family history of deep vein thrombosis (DVT), which renders venous valves incompetent to cause backflow and increased venous pressure, presents a big risk factor. Those with diseases like diabetes and polyneuropathy also have a greater chance of getting venous stasis ulcers.
Individuals with jobs that involve standing for a long period of time will build up venous pressure in their legs and thus more prone to the disease. On the opposite end, a sedentary lifestyle minimizes the blood-pumping action of calf muscles on venous return, leading to higher venous pressure for developing the condition.
Men who smoke have a higher incidence of venous stasis ulcers, as do persons who are overweight.
What are the Symptoms of Venous Stasis Ulcers?
Prior to the ulcer’s formation, the skin may have been somewhat flaky and itchy. Known as stasis dermatitis, this pre-ulceration condition is an eczema (inflammation of the outer layer of skin) resulted from blood settling into the skin layers, then breaking down and depositing hemosiderin (a iron-storing protein) and melanin (skin pigment), which in turn inhibits the venous system’s ability to adequately pump blood up to the heart.
Typically, the ulcer is an open sore in an area that is swollen and already exhibits a red to brown discoloration that may have been present for some time. The lesion frequently occurs around the inner side just above the ankle, where venous pressure is greatest because of the concentration of large communicating veins there. The base of a venous ulcer is usually red. The surrounding skin is often discolored (brown or purple) and swollen, appearing shiny and tight depending on the amount of swelling. It may even feel warm or hot. There may be a white to yellow tissue over the base that is a type of scar tissue and does not promote healing. A clear to yellow or green drainage may be coming from the wound, with significantly increased discharge and discoloration if the wound is infected.
How do You Diagnose Venous Stasis Ulcers?
Varicose veins, spider veins, and purplish discoloration of the skin are commonly observed in suffering from venous stasis ulcers. In a physical exam, the doctor will first review the patient’s medical history for chronic swelling, diabetes, neuropathy and other conditions linked to venous stasis ulcers. Then, a specialist will examine the wound thoroughly, perform tests such as x-ray and MRI (magnetic resonance imaging), in addition to possibly ordering noninvasive vascular studies, blood tests, and taking samples for wound cultures to differentiate these ulcers from infection (cellulitis) or blood clots.
How do You Treat Venous Stasis Ulcers?
Venous ulcers are costly to treat, and there is a significant chance of recurrence — one study found that up to 48% of venous ulcers had recurred by the fifth year after healing. They also may take a long time to heal, with up to 50% of the ulcers open and unhealed for nine months or longer, especially when the patients continue to smoke, remain obese, and not heed the doctor’s orders.
Treatment is geared toward decreasing the swelling so the ulcer can heal. Antibiotics are not routinely administered unless the wound is grossly infected.
Self-Care at Home
The treatment of all ulcers begins with careful skin and foot care. Often you’re given instructions to care for your wound at home similar to the following:
- Keep the wound clean and dry. Gently wash the affected area on your leg and feet every day with mild soap (Ivory Snow or Dreft) and lukewarm water. Washing loosens and removes dead skin and other debris or drainage from the ulcer. You can also clean the ulcer with peroxide, Dakin’s solution, or potassium permanganate once per day. Pat your skin and feet, including between the toes, gently and thoroughly to dry them. Do not rub your skin or the space between the toes. Apply a lanolin-based cream once or twice a day to your legs and the soles and top of your feet to prevent dry skin and cracking, but NEVER apply lotion between your toes or on an open cut or sore.
- Examine your skin and feet daily for cuts, cracks, scratches, blisters, or sores, especially if you have diabetes. Also check for redness, increased warmth, ingrown toenails, corns, and calluses. Use a mirror to view the bottom of your foot or have someone look at it for you. Detecting and treating foot/skin sores early can help you prevent infections and a sore from getting worse. However, do not treat corns, calluses, or other foot problems yourself. Visit a podiatrist for treatment instead.
- Care for your toenails regularly. Cut your toenails after bathing when they’re soft. Cut toenails straight across and smooth with a nail file.
- Change the dressing and take prescribed medications as directed. If you have varicose veins, you will notice your feet and ankles are generally normal in size in the morning but get progressively more swollen as the day goes on. For this reason, it is important to have a dressing change with fresh compression in the morning as to not let the foot and leg swell during the course of the day.
- Elevation of the legs as much as possible.
- Drink plenty of fluid.
- Follow a healthy diet as recommended, including plenty of fruits and vegetables.
- Exercise regularly, as directed by a physician.
- Wear appropriate shoes.
- Wear compression wraps if appropriate and as directed.
- Avoid topical antibiotics, which do not improve ulcer healing. Stay away from topical antiseptics (for example, povidone-iodine), which causes additional injury to the wound and delays healing.
Medical treatments generally include one or more of the following options in addition to home care:
1. Weekly application of Unna’s boot compressive dressing (which contains zinc oxide) to minimize edema (swelling caused by fluid trapped in your body’s tissues) and other types of swelling.
2. Support hose. Non-elastic, moveable, below-knee compression will aggressively counter the impact of reflux on venous pump failure. It can decrease blood vessel diameter and pressure, in turn increasing their effectiveness and prevent blood from flowing backward.
3. Antibiotics if wound becomes infected.
4. Consultation for vascular surgery if necessary.
The ulcer itself generally has to be treated in an effort to remove all devitalized tissue and to promote formation of healthy granulating tissue. Debridement or removal of this dead tissue may be done in a couple of different ways. The most common is through sharp debridement where your doctor takes a scalpel and scrapes away all dead tissue within the ulcer and immediately surrounding the wound. The problem with this is that it can be a painful procedure and at times may have to been done under local anesthesia.
Surgical treatment is reserved for those with great discomfort or ulcers that don’t seem to respond to noninvasive medical treatments and management. The most common procedure is a sharp debridement in which the doctor takes a scalpel and scrapes away all dead tissue within the ulcer and immediately surrounding the wound. It can, however, be a painful ordeal and at times may have to be done under local anesthesia.
How to Prevent Venous Stasis Ulcers?
Controlling the risk factors can help you prevent venous stasis and other ulcers from developing. Your options include:
- Elevate your legs when sitting
- Change your position when you stand or sit for a long time
- Wear any support socks or stocking as ordered by your doctor
- Avoid tight clothing
- Eat a well-balanced diet to control your weight, blood cholesterol, and triglyceride (a type of fat) levels
- Limit your intake of sodium
- Manage your blood pressure
- Exercise regularly; this can be as simple as walking a few extra blocks or climbing a flight of stairs a day (but check with your doctor before starting any exercise program)
- Quit smoking