Venous ulcers of the shin

The Phlebology Clinic / Venous insufficiency of the lower limbs / Venous ulcers of the shin

Venous leg ulceration - a serious complication of chronic venous insufficiency. A visible wound on the leg with trophic skin changes characteristic of venous disease. The photograph shows an advanced stage of venous disease requiring urgent consultation with a phlebologist.

Introduction

Venous ulcers of the shin (venous leg ulcers, VLUs) is a complication of the chronic venous disease, a condition affecting the venous system of the legs in up to 55% of the female population and 30% of the male population. Chronic venous insufficiencywhich occurs when venous insufficiency is poorly treated or not treated, can lead to venous ulcers of the shin. Venous ulcers are a complication of venous disease characterised by difficult healing and a tendency to recur.

Venous ulcers of the shin are the most common type of all lower limb ulcers. In Europe, they affect 1.0-1.5% populationand in people over 65 life, this percentage increases to 3%. The problem of venous insufficiency in people is increasing during their lifetime, we are living longer and longer, and chronic venous insufficiency and the resulting trophic skin changes are the main cause of this. Patients with venous ulcers of the shin often experience recurrence, continuous opening and wound healing.

Prompt recognition of chronic venous disease, especially the stages of C3, C4The treatment of venous leg ulcers is difficult, lengthy and very costly. The treatment of venous leg ulcers is difficult, lengthy and very expensive, so it is best to deal with venous insufficiency at its earlier stages (C1, C2).

Varicose veins on the skin of the leg. Pre-ulcerative condition. Female.

Description of the condition

Venous ulcers of the shin are tissue defects (wounds) of varying shape and depth. They can be circular and very deep. A typical venous ulceration is usually located in the ankle area, usually on the medial side (where trophic changes of the skin, its congestive inflammation and thinning usually occur). They are characterised by an irregular shape, swelling of the surrounding tissues and a foul-smelling discharge that occurs during the active phase. The pain experienced by the patient can range from mild to very severe, keeping the patient awake at night. This pain usually decreases after compression therapy and after elevation of the leg. The onset of ulceration may be sudden (there is trauma or inflammation, rupture and bleeding of the varicose vein, slow infection of the skin) or latent (persistent scab).

Around a venous ulceration there are often skin changes such as:

discolourations (hyperpigmentation; C4a) - discolouration is caused by the deposition of haemosiderin (dermal-tissue haemosiderosis), a pigment derived from the breakdown of haemoglobin found in red blood cells; iron deposits are deposited in the affected skin and subcutaneous tissue, leading to rusty shades;
venous eczema (eczema; C4a) - occurs as a result of an inflammatory reaction in the skin, manifested by redness, itching, blistering and flaking;
dermo-fatty sclerosis (lipodermatosclerosis; C4b) - is a condition in which fibrotic changes and subcutaneous thickening occur, often accompanied by hyperpigmentation and inflammation, which can be a recurrent phenomenon.

Left lower leg with venous ulceration of the shin. Authored by Dr Tomasz Grzela. Department of Phlebology. — **Cleared venous ulceration of the shin (C6). Most common location - above the medial ankle of the left lower limb. Author: Tomasz Grzela, MD**

In the CEAP classification (2020 revision), venous ulcers of the shin are assigned to two subcategories:

– C5: this scar after venous ulceration;
– C6: is a character active venous ulceration (The wound is open - as in the accompanying photo).

In the C5 form (healed venous ulceration), scarred fibrous tissue is visible at the site of the healed wound. The subcutaneous tissue and the skin itself are altered in this area, thin and vulnerable to the occurrence of another ulceration. We then speak of active recurrent ulceration.
In the form of C6 we are dealing with an open wound, which very often does not show any tendency to heal and, on the contrary, is able to widen and occupy further parts of the shin.

The CEAP classification, although simple and useful in phlebology, does not provide enough information to differentiate patients with venous ulcers in terms of the clinical assessment of the ulceration. A more detailed assessment of the condition of the ulceration, its size, depth, amount of discharge, the condition of the surrounding skin and other factors is essential to select an appropriate treatment.

In untreated ulcers, the phenomenon of autonomisation occurs. Such an ulcer becomes resistant to treatment. This is due to the fact that its bottom fibroses. This leads to further devascularisation of the woundThe blood supply to the ulcer bed and surrounding tissues is impaired or lost. This is a process characterised by a reduction in the number of functional blood vessels or their malfunction. This exacerbates tissue hypoxia and further fibrosis. Therefore, early surgical debridement of the wound (photo opposite), debridement of the ulcer and later reduction of venous hypertension and reflux in the affected lower limb is important.

Patients with venous ulceration of the shin may experience complications. Rupture of the varicose vein supplying the ulcerated tissue occurs, and infectious complications or neoplastic transformation of the tissue can occur. The latter phenomenon is known as Marjolina ulcers Affects approximately 0.5-2% of all venous ulcers. It occurs most commonly in the form of squamous cell carcinoma, a type of skin cancer characterised by aggressive growth and a tendency to infiltrate neighbouring tissues and give metastases.

Risk factors

age - The risk of venous ulceration increases with age.
female gender - venous ulcers in women are 2.5-3 times more common than in men; the peak incidence in women is between 60 and 80 years of age.
genetic predisposition - Heredity increases the risk of venous ulceration by up to 2-3 times.
number of pregnancies and births in women - hormonal changes, post-pregnancy pelvic venous insufficiency and increased risk of thrombosis are the most common factors that increase the risk of ulceration in women giving birth.
history of venous disease - people who have been suffering from chronic venous disease for longer develop more frequent complications; in addition, these people are more likely to develop venous thrombosis, which leads to post-thrombotic syndrome (one of the more common causes of venous ulceration).
lifestyle factors - Standing or sedentary work and lack of physical activity are the most important lifestyle risk factors.
obesity - Excessive body weight puts a strain on the venous system and increases the risk of complications of chronic venous disease.
incidents venous thrombosis lead to the development of post-thrombotic syndrome, a disease phenomenon that strongly increases venous hypertension.

Surgical treatment of varicose veins at the Phlebology Clinic. Vein mapping for phlebectomy. — **Delayed treatment of venous disease (C2-C3) is one of the more common causes of the formation of skin complications (C4) and venous ulceration (C5-C6).**

Mechanism of formation

Venous ulcers of the shin are the result of complex pathological processin which progression plays a major role chronic venous insufficiency. In the course of venous disease there is a increase in venous pressure in the vascular bed of the legs (This creates a so-called venous hypertension). This in turn causes damage to the capillary structure and causes seepage of fluid into surrounding tissueswhich manifests itself as swelling.

A key role in the development of venous ulcers is played by the processes of inflammation of the subcutaneous tissue and tissue overload with iron, which is a breakdown product of haemoglobin from extravasated blood. Chronic venous hypertension causes inflammationwhich damages not only capillaries but also skin cells, fibroblasts. Fibroblasts change their phenotype to myofibroblastswhich, by contracting, increase the tension in the dermis. This increased tension causes the skin to become more susceptible to injury and impedes wound healing.

Cutaneous haemosiderosis (iron overload) sustains inflammation and hinders the healing. Iron, derived from haemoglobin, accumulates in the intercellular space of the skin and activates macrophages (foraging cells), keeping them ready to respond chronically to inflammation. This mechanism blocks the conversion of macrophages into other beneficial ones, which are responsible for repair mechanisms in our tissues. The protracted inflammatory process also changes the structure of the extracellular matrix (ECM)which provides a scaffolding for the skin cells. Damage to this scaffolding impedes the migration of keratinocytes, i.e. those cells responsible for epidermal regeneration. This is a mechanism that further delays ulcer healing.

It is worth noting that treating venous disease at an early stage of development (C2-C3) significantly reduces the risk of its skin and thrombotic complications, significantly reducing the incidence of venous ulcers of the shin. Early intervention, e.g. in the form of compression therapy (compression therapy) or causal intravenous treatment can effectively reduce venous hypertension and prevent the development of inflammatory lesions in the skin. This can avoid serious complications such as: corona phlebectatica (C4c - photo above), active venous ulceration (C6) or scar after healed ulceration venous (C5).

Recognition and diagnosis

The diagnosis and diagnosis of the problem of venous ulceration of the shin is based on a detailed medical history, physical examination and the performance and ordering of additional investigations, including in-depth diagnostic imaging. Although 'diseased veins' are mostly responsible for venous leg ulcers, there are many other causes of leg wounds (20-30% are 'non-venous' causes).

In the first instance, the phlebologist should collect a thorough medical history and analyse:

the patient's venous history;
the presence of symptoms of chronic venous insufficiency, such as pain, oedema and a feeling of heaviness in the legs;
risk factors for the development of venous disease, such as age, pregnancy history - in the case of women, weight changes over time and lifestyle errors;
past trauma, venous surgery/procedures and orthopaedic or gynaecological surgery in the case of women.

The following is done physical examinationThis should include an assessment of the state of the skin, the presence of typical venous disease symptoms and an analysis of the ulceration itself (its location, size, depth, condition of the wound edges, amount of discharge or presence of necrotic tissue).

Additional investigations are performed to confirm the diagnosis and exclude other causes of the ulceration, as well as to assess the severity of the venous disease. The basic diagnostic test is the measurement of ankle-brachial index (ABPI). It is a non-invasive test to assess blood flow in the arteries of the lower limbs. The ABPI is calculated by dividing the systolic pressure measured on the dorsal artery of the foot by the systolic pressure measured on the brachial artery.

Phlebologists reach for other tests in the diagnosis of venous ulcers. The basis of diagnosis is always Doppler ultrasonography of the venous system with assessment of the veins of the abdominal cavity, small pelvis and veins of the lower limbs. The analysis of the affected leg must always be carried out in a loaded position (standing, possibly sitting). The aim of the Doppler examination is to exclude post-thrombotic changes. Patients with a history of venous thrombosis usually suffer from venous leg ulcers, which are the most difficult to treat. Sometimes the venous system needs to be examined more closely and other causes of (external) increased intravenous pressure need to be excluded. Imaging studies such as computed tomography or magnetic resonance venography are then used. Such examinations are usually performed with the administration of an intravenous contrast agent. It should be borne in mind that venous ulcers of the shin are mainly suffered by elderly people, and that they statistically have a higher incidence of other conditions that may exacerbate venous disease or the formation of the ulcers themselves by a mechanism other than 'venous'.
In selected - untreatable cases - it is sometimes performed venous ulcer biopsy. As is well known, some patients encounter neoplastic transformation of a chronic wound (see section: "Description of the condition").

Venous ulcers of the shin should be differentiated with other diseases that can lead to wounds on the legs. Leg ulcers can also have a different origin and background. The most common is the aetiology:

arterial: This type of ulceration occurs in patients with peripheral arterial disease and is characterised by severe pain, pale and cold skin around the wound, lack of hairiness, and low ABPI (< 0.8).
neuropathic (so-called diabetic foot): occur in patients with diabetes and are characterised by a lack of pain sensation, as well as deformities of the foot.
mixed (e.g. arteriovenous): occur in patients with peripheral arterial disease and chronic - complicated - venous insufficiency.
cancer: can vary in appearance, usually characterised by faster progression than venous ulcers and lack of healing.

Treatment methods

The main treatment methods for venous leg ulcers - in addition to changing modifiable risk factors and improving lifestyles - include:

compression therapyor pressure treatment: this is the primary method of treating venous ulcers. It involves the use of multi-layer applied bandages or compression stockings and knee socks for healed (C5) ulcers. Compression devices reduce oedema and improve venous blood flow and microcirculatory function. There are different types of bandages, wraps and high-stretch devices with varying degrees of compression. Choosing the right type depends on the severity of the condition.
pharmacological treatment: Phlebotropic drugs improve venous wall tone and reduce capillary permeability. Antibiotics are sometimes resorted to when bacterial infections occur.
lection of local treatment using dressings: involves the use of special dressings that absorb secretions, change the wound environment and promote healing; the type of dressing is always selected individually, depending on the state of the ulcer and the amount of secretions.
surgical treatment (local) - is used to cleanse the wound and speed up healing; sometimes a phlebologist or surgeon decides to use skin grafting - the procedure involves taking a thin piece of healthy skin, usually from the thigh or buttock, and placing it on the cleaned bottom of the ulcer. The graft acts as a biological dressing, speeding up tissue regeneration, reducing the risk of infection and promoting healing.
surgical treatment of venous insufficiency - Patients with venous ulceration of the shin are usually treated with intravenous methods, which are more effective and have fewer skin complications than surgical methods; surgical treatment is aimed at reducing venous hypertension, which results in faster healing and a lower rate of recurrence, thus conversion from stage C5 to C6.

Venous ulceration of the shin is a serious condition that requires appropriate diagnosis and targeted and symptomatic treatment. Remember that early diagnosis of venous disease and the implementation of appropriate therapy and the use of compression devices, prevents the occurrence of venous ulceration. Prevention is the best form of therapy for venous leg ulcers.

Mostly
questions asked

A characteristic feature of chronic wounds is their colonisation by bacteria, It is therefore extremely unlikely that the wound culture is sterile. It is true that in most wounds, the presence of bacteria can slow down the healing process somewhat, but usually these wounds do not require treatment with an antibiotic. Furthermore, the use of an antibiotic may in some cases do more harm than good. Let's remember, DO NOT use topical antibioticsThe wound should be treated with a wound preparation, i.e. a cream or ointment applied to the wound. If the condition of the wound requires it, the doctor should prescribe it, preferably on the basis of the wound biopsy culture, treatment with oral or, in exceptional cases, even intravenous antibiotics.
In most cases, the use of specialised dressings and tourniquets is entirely sufficient. However, in some cases, Patients may require surgical treatment (intravenous or surgical) to achieve wound healing. This is usually the case for Patients with large wounds, and with very heavy exudate.
In the past, surgical treatment consisted of surgical removal of the incompetent superficial vein (saphenous or saphenous vein), but nowadays minimally invasive methods are usually used for this purpose - intravascular laser ablation, varicose vein gluing or chemical obliteration, or so-called compression sclerotherapy. At the Phlebology Clinic, we also carry out procedures to close inefficient veins with a special adhesive. Using the latter method, we have achieved the healing of problematic wounds in many patients who were previously disqualified from surgical treatment by other methods. Fortunately, such cases are extremely rare.
It is also worth mentioning the latest treatment options for patients with recurrent ulcers who have post-thrombotic lesions in the deep veins of the thigh and/or pelvis. In at least some such patients, improved healing or reduced chances of ulcer recurrence can be achieved by inserting a special stent into the affected vein. However, the success of such a procedure largely depends on the proper qualification of the patient for the procedure - preferably carried out after a thorough imaging study, such as magnetic resonance venography.
Occasionally, a venous ulceration may heal partially. However, spontaneous (without intervention) and complete healing of a venous leg wound is unlikely. To aid the healing process, it is crucial to use compression therapy, maintain wound hygiene and use specialised dressings. It is important to remember that neglecting a venous ulcer can end badly, with infection and systemic complications that affect the whole body (e.g. sepsis).
Yes, a skin graft can be an effective method of speeding up the healing of a venous ulcer, especially those that are large, deep or otherwise difficult to heal. A skin graft involves taking a piece of healthy skin from elsewhere on the patient's body and placing it at the bottom of the ulcer.
Here is some additional information on skin grafts for the treatment of ulcers:
Pros:
- accelerating healing: Transplanting a skin flap can significantly speed up the healing process of the ulcer, as it provides healthy tissue that can start the regeneration process.
- Scar reduction: Skin grafts can help to reduce the visibility of ulcer scars.
Disadvantages:
- risk of rejection: there is a risk that the patient's body will reject the skin graft.
- pain and discomfort: Taking skin and transplanting it onto an ulcer can be painful and cause discomfort.
- infection: The transplant site is vulnerable to infection.
- cost: Skin grafts can be costly.
The choice of dressing used at the site of an established venous shin ulcer depends on a number of factors, including the size and depth of the ulcer, the amount of exudate, the presence of infection in the wound and the condition of the skin around the ulcer.
We use several types of dressings in the treatment of venous shin ulcers:
- hydrocolloid: create a moist healing environment, absorb exudate and protect the wound from trauma. They are suitable for ulcers with low to moderate amounts of exudate;
- alginate: based on seaweed, are highly absorbent and haemostatic (prevents bleeding). They are suitable for ulcers with a lot of exudate.
- foam: available in different thicknesses and shapes, provide wound protection and absorb exudate. They are suitable for ulcers with moderate amounts of exudate;
- hydrogel: provide a moist healing environment, cool the wound and promote autolytic wound debridement. They are suitable for ulcers with little exudate and dry wounds;
- silver additive: have an antibacterial effect and are used to treat infected ulcers.
Remember that the selection of an appropriate dressing should always be consulted with your GP or nurse.
The most effective method of treating venous leg ulcers is to compression therapy (compression therapy) combined with appropriate wound care and the use of dressings prescribed by the doctor. A multilayer bandaging system is usually used for this purpose. The aim is to reduce the prevailing venous hypertension and create the conditions for the skin and subcutaneous tissue to heal.

Related issues

Closing of perforators

At the Department of Phlebology, we have developed a proprietary method of closing inefficient perforating veins in patients with venous ulceration of the shin.

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