Continuing Medical Education
Chronic venous insufficiency and venous leg ulceration

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Abstract

Venous ulcers are the most common form of leg ulcers. Venous disease has a significant impact on quality of life and work productivity. In addition, the costs associated with the long-term care of these chronic wounds are substantial. Although the exact pathogenic steps leading from venous hypertension to venous ulceration remain unclear, several hypotheses have been developed to explain the development of venous ulceration. A better understanding of the current pathophysiology of venous ulceration has led to the development of new approaches in its management. New types of wound dressings, topical and systemic therapeutic agents, surgical modalities, bioengineered tissue, matrix materials, and growth factors are all novel therapeutic options that may be used in addition to the “gold standard,” compression therapy, for venous ulcers. This review discusses current aspects of the epidemiology, pathophysiology, clinical presentation, diagnostic assessment, and current therapeutic options for chronic venous insufficiency and venous ulceration. (J Am Acad Dermatol 2001;44:401-21.)

Learning objective: At the conclusion of this learning activity, participants should be familiar with the 3 main types of lower extremity ulcers and should improve their understanding of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic assessment, and current therapies for chronic venous insufficiency and venous ulcers.

Section snippets

Epidemiology

Venous leg ulcers are responsible for more than half of lower extremity ulcerations, with an overall prevalence ranging from 0.06% to 2%.6, 8 This variance may be due to contributory factors including the use of overall versus point prevalence; the inclusion or exclusion of foot ulcers; the age and sex distribution of the patient series; the methodology used to identify patients6, 18; the patients' often inaccurate assessment of ulcer duration, healing, and recurrence; and the lack of a uniform

Normal anatomy and physiology

Venous blood flow of the lower extremity is divided into 3 components: the superficial, communicating, and deep veins. The superficial system comprises both the long and short saphenous veins and their tributaries. The long saphenous vein originates from the medial end of the dorsal venous arch of the foot and ascends the leg and thigh medially. It joins the femoral vein just below the inguinal ligament. The lesser or short saphenous vein originates from the lateral aspect of the dorsal venous

Patient history

The clinical history of patients with venous ulceration is characterized by the lack of specific symptoms. There is variable discomfort associated with venous ulcers, the severity of which varies unpredictably between patients and their particular ulcers. The surface area of the ulcer does not correlate well with the presence of pain. Deep ulcers, particularly around the malleoli, or small venous ulcers surrounded by atrophie blanche are the most painful. Patients with venous ulcers commonly

Risk factors for venous leg ulceration

Most epidemiologic studies on chronic venous insufficiency are cross-sectional surveys that suggest potential risk factors by describing their study population. However, these relationships could be due to the older age of the population with chronic venous insufficiency. Scott et al76 conducted a prospective dual case-control study to address this issue. They found that in addition to being older, patients with chronic venous insufficiency tend to be obese. They also commonly report a history

Clinical presentation

One of the first obvious clinical signs of chronic venous insufficiency is varicose veins, although the recently described acute lipodermatosclerosis (see below) may precede the presence of varicosities.85 The size of varicose veins may range from a submalleolar venous flare to various degrees of vessel dilation (Figs 2 and 3).

. Varicosities are commonly the first sign of venous disease. A, Dilated long saphenous vein. B, Classic submalleolar venous flare.

. Ulcer in a typical location, above the

Differential diagnosis

Although most leg ulcers in large series are venous, the pathogenesis is not venous in all patients.1 Other common causes are arterial and neuropathic; however, the cause of an ulcer is often multifactorial.100

Arterial ulcers typically appear round or punched out with a sharply demarcated border.7, 9, 86 A fibrous yellow base or a true necrotic eschar with scant or absent granulation tissue is commonly seen. Necrotic tissue or the exposure of tendons and deep tissues also suggests an arterial

Assessment for venous insufficiency

In up to 76% of the cases, the diagnosis of venous ulceration may be made by clinical criteria alone.109, 110 Noninvasive methods are helpful for accurate diagnosis and anatomic and functional evaluation, but do not exclude overlapping causes for the ulceration.9, 110

Measurement of the ABI by Doppler ultrasonography, as described earlier, is useful to exclude concomitant arterial disease because compression therapy in patients with undiagnosed arterial insufficiency can lead to ulcer worsening,

Treatment

Treatment goals for patients with chronic venous insufficiency include reduction of edema, alleviation of pain, improvement of lipodermatosclerosis, healing of ulcers, and prevention of recurrence.29 Better understanding of the pathophysiology of venous disease and leg ulceration has in turn suggested new approaches to the management of ulcer disease with new types of wound dressings, compression bandages, topical and systemic therapeutic agents, and surgical modalities.8

The primary role of

References (237)

  • JL Burton

    Livedo reticularis, porcelain-white scars, and cerebral thromboses

    Lancet

    (1988)
  • A Greenberg et al.

    Acute lipodermatosclerosis is associated with venous insufficiency

    J Am Acad Dermatol

    (1996)
  • DJ Margolis et al.

    Fibrinolytic abnormalities in 2 different cutaneous manifestations of venous disease

    J Am Acad Dermatol

    (1996)
  • A Falabella et al.

    Uncommon causes of ulcers

    Clin Plast Surg

    (1998)
  • RG Sibbald

    An approach to leg and foot ulcers: a brief overview

    Ostomy Wound Management

    (1998)
  • SR Baker et al.

    Epidemiology of chronic venous ulcers

    Br J Surg

    (1991)
  • JV Cornwall et al.

    Leg ulcers revisited

    Br J Surg

    (1983)
  • MJ Callam et al.

    Chronic ulceration of the leg: extent of the problem and provision of care

    Br Med J

    (1985)
  • MJ Callam et al.

    Hazards of compression treatment of the leg: an estimate from Scottish surgeons

    Br Med J

    (1987)
  • O Nelzen et al.

    Venous and non-venous leg ulcers: clinical history and appearance in a population study

    Br J Surg

    (1994)
  • MP Goldman et al.

    The Alexander House Group: consensus paper on venous leg ulcer

    J Dermatol Surg Oncol

    (1992)
  • V Falanga

    Venous ulceration: assessment, classification and management

  • D Krasner

    Painful venous ulcers: themes and stories about their impact on quality of life

    Ostomy Wound Management

    (1998)
  • PD Coleridge-Smith et al.

    Causes of venous ulceration: a new hypothesis?

    Br Med J

    (1988)
  • RG Sibbald

    Venous leg ulcers

    Ostomy Wound Management

    (1998)
  • T Phillips

    New skin for old: developments in biological skin substitutes

    Arch Dermatol

    (1998)
  • DL Steed et al.

    Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. Diabetic Ulcer Study Group

    J Vasc Surg

    (1995)
  • D Bergqvist et al.

    Chronic leg ulcers: the impact of venous disease

    J Vasc Surg

    (1999)
  • WW Coon et al.

    Venous thromboembolism and other venous disease in the Tecumseh Community Health Study

    Circulation

    (1973)
  • MJ Callam et al.

    Chronic ulcer of the leg: clinical history

    Br Med J

    (1986)
  • CV Ruckley

    Socioeconomic impact of chronic venous insufficiency and leg ulcers

    Angiology

    (1997)
  • KJ Harkiss

    Cost analysis of dressing materials used in venous leg ulcers

    Pharm J

    (1985)
  • JE Gjores

    Symposium on venous ulcers: opening comments

    Acta Chir Scand

    (1988)
  • DA Simon et al.

    Approaches to venous leg ulcer within the community: compression, pinch skin grafts and simple venous surgery

    Ostomy Wound Management

    (1996)
  • GS Lazarus et al.

    Definitions and guidelines for assessment of wounds and evaluation of healing

    Arch Dermatol

    (1994)
  • JW Olin et al.

    Medical costs of treating venous stasis ulcers: evidence from a retrospective cohort study

    Vasc Med

    (1999)
  • V Falanga

    Venous ulceration

    J Dermatol Surg Oncol

    (1993)
  • FW Gourdin et al.

    Etiology of venous ulceration

    South Med J

    (1993)
  • PC Alguire et al.

    Chronic venous insufficiency and venous ulceration

    J Gen Intern Med

    (1997)
  • KG Burnand et al.

    The relative importance of incompetent communicating veins in the production of varicose veins and venous ulcers

    Surgery

    (1977)
  • CC Arnoldi

    Venous pressure in patients with valvular incompetence of the veins of the lower limb

    Acta Chir Scand

    (1966)
  • V Falanga
  • O Nelzén

    Surgical options and indications for surgery in the treatment of patients with venous leg ulcers

  • RD Leach et al.

    Effect of venous hypertension on canine hind limb lymph

    Br J Surg

    (1985)
  • V Falanga et al.

    Pericapillary fibrin cuffs in venous ulceration

    J Dermatol Surg Oncol

    (1992)
  • KG Burnand et al.

    Pericapillary fi-brin in the ulcer-bearing skin of the lower leg: the cause of lipodermatosclerosis and venous ulceration

    Br Med J (Clin Res Ed)

    (1982)
  • HAM Neumann et al.

    Transcutaneous oxygen tension in chronic venous insufficiency syndrome

    Vasa

    (1984)
  • HAM Neumann et al.

    Transcutaneous oxygen tension in patients with and without pericapillary fibrin cuffs in chronic venous insufficiency, porphyria cutanea tarda and non-venous leg ulcers

    Vasa

    (1996)
  • HAM Neumann

    Possibilities and limitations of transcutaneous oxygen tension: measurements in chronic venous insufficiency

    Int J Microcirc Clin Exp

    (1990)
  • R Mani et al.

    Tissue oxygenation, venous ulcers and fibrin cuffs

    J R Soc Med

    (1989)
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    Reprint requests: William H. Eaglstein, MD, Chairman and Harvey Blank Professor, Department of Dermatology and Cutaneous Surgery, University of Miami, School of Medicine, Room 2023, RMSB (R-250), 1600 NW 10th Ave, Miami, FL 33136.

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