Venous Stasis Ulcer

Chronic wound in the lower leg (typically the gaiter area, near the medial malleolus) caused by sustained venous hypertension from superficial, perforator or deep venous reflux, or from obstruction. It accounts for about 70 to 80% of leg ulcers, and affects about 0.5 to 1% of adults and 1 to 3% of those over 65.

• Risk factors: previous deep vein thrombosis, varicose veins, obesity, advanced age, multiple pregnancies, previous leg injury or fracture, immobility, family history and heart failure.
• Mechanism: venous hypertension, capillary leak with fibrin cuff formation, white cell trapping with inflammation, haemosiderin deposition and skin breakdown.
• With appropriate compression, about 50 to 70% heal by 24 weeks. Recurrence is about 30 to 70% within a year in the absence of continued compression and correction of reflux.

• Shallow, irregular ulcer with a granulating or sloughy base and moderate to heavy exudate, in the gaiter area, near the medial malleolus, painless to moderately painful and relieved by elevation.
• Surrounding skin: oedema, brown haemosiderin staining, venous eczema, lipodermatosclerosis (hard woody skin with an inverted champagne bottle shape), atrophie blanche, varicose veins, corona phlebectatica. Pedal pulses are present.
• Differential diagnosis: arterial ulcer (distal, painful, punched out, absent pulses), diabetic neuropathic ulcer, pressure injury, vasculitis, pyoderma gangrenosum, squamous cell carcinoma in a long standing ulcer (Marjolin ulcer), basal cell carcinoma, sickle cell ulcer, tropical ulcer, Buruli ulcer, cutaneous tuberculosis, leishmaniasis, calciphylaxis, contact dermatitis, and lymphoedema.
• Complications: cellulitis, contact sensitivity to dressings and topical agents, malignant change (less than 1%), chronic pain, osteomyelitis (rare), reduced mobility and recurrence.

• Clinical. Measure the ankle brachial pressure index before any compression:
  • 0.8 to 1.3: full compression is safe.
  • 0.5 to 0.8: mixed disease; use reduced compression (20 to 30 mmHg) under specialist supervision.
  • Less than 0.5: do not apply compression; refer urgently to a vascular service.
• Duplex ultrasonography of the superficial and deep veins to define reflux (reflux time greater than 0.5 seconds in superficial and perforator veins, greater than 1.0 second in femoral and popliteal veins) and obstruction.
• Swab only for clinical infection. Biopsy for an atypical ulcer, a rolled or raised edge, or failure to heal after 12 weeks of treatment, to exclude malignancy or vasculitis.
• Blood tests: full blood count, HbA1c, creatinine, albumin, ferritin, HIV test, haemoglobin electrophoresis or sickle test where relevant; patch testing for refractory eczema.

• Compression is the core treatment:
  • Multilayer (four layer) or short stretch compression bandaging from the toes to the knee, giving about 35 to 40 mmHg at the ankle, changed weekly (twice weekly with heavy exudate). Compression raises healing rate by about 50% compared with no compression.
  • Do not apply compression with ankle brachial pressure index less than 0.5, uncontrolled heart failure, or severe peripheral neuropathy without close supervision.
  • After healing, class 2 or 3 compression stockings (20 to 30 or 30 to 40 mmHg) worn daily for life.
• Wound care:
  • Cleanse with saline or tap water; remove slough by autolytic (hydrogel), sharp or larval debridement; moisture balancing dressings (alginate, hydrofibre or foam for exudate); avoid topical antibiotics and sensitising agents (neomycin, lanolin, fragrances).
  • Surrounding skin: emollients; for venous eczema mometasone furoate 0.1% ointment once daily for 1 to 2 weeks.
• Infection (only when there are clinical signs: increased pain, spreading erythema, purulent exudate, odour, fever):
  • Flucloxacillin 500 mg four times daily for 7 days; clindamycin 300 to 450 mg three times daily if penicillin allergic. Extend to 10 to 14 days for deeper infection; admit for sepsis.
• Pain and mobility:
  • Paracetamol 1 g four times daily, a short course of ibuprofen 400 mg three times daily with food when safe, and elevation of the leg for 30 minutes several times daily.
  • Calf muscle exercise, ankle movement and walking; weight loss; treat heart failure and oedema.
• Adjuncts:
  • Pentoxifylline 400 mg three times daily (modified release 400 mg three times daily) added to compression speeds healing (evidence is moderate).
  • Micronised purified flavonoid fraction 500 mg twice daily may help (evidence is limited).
  • Skin grafting (split thickness or pinch grafts) for large or persistent ulcers; cellular and matrix therapies in specialist units.
• Correct venous reflux and obstruction (reduces recurrence from about 28% to 12% at 4 years):
  • Endovenous thermal ablation (laser or radiofrequency), foam sclerotherapy with polidocanol 1 to 3% (maximum 10 mL per session), or surgical ligation and stripping of incompetent superficial veins, performed soon after the ulcer is under treatment and without waiting for healing.
  • Perforator ablation for incompetent perforators beneath the ulcer.
  • Venous angioplasty and stenting for iliac vein obstruction.
• Prevention of recurrence: lifelong compression stockings, treatment of reflux, skin care, exercise, weight control and early treatment of any new skin breakdown.
• Special groups:
  • Diabetes: check arterial supply and neuropathy; careful foot care and infection control.
  • Sickle cell disease: leg ulcers need compression, wound care, hydroxyurea 15 mg/kg/day (adjusted to blood count) and transfusion as advised by haematology.
  • HIV and malnutrition: treat infection, optimise nutrition (protein and zinc), antiretroviral therapy.
  • Mixed arterial and venous disease: reduced compression and vascular review.
  • Elderly: help with bandage application; skin care and fall prevention.
• Red flags: signs of infection, spreading cellulitis, sudden severe pain, rolled edge or non-healing at 12 weeks (biopsy), ankle brachial pressure index less than 0.5, bleeding from a varix.
• Follow up: weekly dressing and bandage changes until healing; measure area at 4 weeks (aim for 40% reduction) and refer for vascular assessment if there is less; review at 1 month after healing, then every 3 to 6 months for stocking fit and skin check.