Venous Insufficiency and Venous Ulcers
Saturday, January 01, 2011
Stasis dermatitis and ulcers are complications of chronic venous
insufficiency. Sixty percent of leg ulcers are due to venous
insufficiency, and 30% more are associated with a combination of
arterial and venous insufficiency.
Stasis dermatitis typically appears above the medial malleolus.
It is complicated by xerosis and allergic contact dermatitis in
If available, treatment is with paromomycin sulfate 15% and
methylbenzethonium chloride 12% in white soft paraffin applied
twice daily for 10 days.
- Control of edema is mandatory!
- Elevate the lower extremity by raising the foot above the level
of the heart while the patient is sitting. When possible, encourage
lower-extremity muscle-pump activity by having the patient walk;
discourage standing, but encourage "toe-risers" when standing is
- Employ elastic stockings of at least 30 mmHg to firmly but
gently compress the extremity.
- Prescribe a medium-potency topical corticosteroid cream twice
daily to dermatitic skin. Compression stockings may be worn after
steroid application. Expect resolution of dermatitis in 7-14
- If cellulitis is present, treat with an appropriate oral
antibiotic to cover streptococci and staphylococcus. If the patient
fails to respond after 48-72 hours, is febrile, or has an elevated
white blood cell count, hospitalize the patient, culture the blood,
and treat the patient with intravenous antibiotics to provide
coverage for staphylococcal and streptococcal infection.
- Continue compression and elevation therapy.
- Xerosis and scaling frequently follow dermatitis; apply an
emollient regularly as needed.
Control of edema by simple physical measures may not be possible
in some individuals. For such patients, consider evaluation for
another cause of the persistent edema (cardiac, hepatic, or renal
- Peripheral edema may be caused by mechanisms other than venous
insufficiency. Consider congestive heart failure, lymphatic
obstruction (cancer), renal failure, or hepatic disease.
- Dermatitis may be from contact dermatitis rather than stasis.
Patients may have used topical preparations containing lanolin,
parabens, ethylenediamine, neomycin, or other sensitizers. An
adequate history and appropriate patch testing are keys to
confirming this diagnosis.
Venous Insufficiency Ulceration/Stasis Ulcer
Stasis ulcers are the most common cause of leg ulceration.
Evidence of venous insufficiency may be minimal, so in some cases
vascular evaluation (Doppler) may be required to confirm venous
insufficiency as the etiology of the leg ulcer. In all ulcerations,
if appropriate and progressive healing does not occur, a biopsy is
indicated. Patients with a tendency to lower leg ulcerations may
have inherited or acquired defects in their fibrinolytic systems.
Appropriate evaluation for these conditions is indicated,
especially if there is a history of prior venous thrombosis.
Arterial insufficiency may coexist. Determining the ratio of the
diastolic blood pressure in the leg vs. the arm (ankle-brachial
index, or ABI) is recommended in all patients, as standard methods
for healing venous ulcerations may be ineffective in the presence
of significant arterial disease (ABI <0.5-0.7).
- Control edema and dermatitis as described above. Control of
edema is essential to improvement of the leg ulcer.
- Treat infection: Excessive drainage, surrounding cellulitis,
tenderness, and failure of a healing ulcer to continue to heal may
be signs of infection. Wound cultures are recommended and
appropriate antibiotic therapy should be given. NOTE: All leg
ulcers will be colonized with bacteria, so finding bacteria by
culture does not diagnose "infection". Cultures of leg ulcers are
only of value if they are obtained in the setting of clinical
findings of infection. The presence of infection is confirmed if
treatment for infection improves the patient's symptoms and the
appearance of the ulcer.
- Debride the ulcer: If there is firm adherent fibrinous exudate
in the ulcer, debridement will accelerate healing. Apply 30%
lidocaine in acid mantle base and wait 20 minutes before gently
debriding with a curette. This can be repeated at each visit, until
all necrotic debris has been removed from the ulcer bed.
- Apply a multilayered dressing and change on a weekly basis. A
typical dressing would include the following:
- Metronidazole to control bacterial overgrowth.
- Becaplermin to stimulate granulation tissue (in slowly
- Desiccated animal collagen (xenograft) if needed to accelerate
wound healing (in slowly responding ulcers).
- Semipermeable dressing over the whole ulceration, sealed at the
periphery. For exudative wounds, fenestrated dressings, or
superabsorptive ones, may be used.
- Unna boot wrap of the whole leg from toes to just below the
- Application of Coban dressing to apply appropriate pressure (30
to 40 mmHg). Multilayered elastic dressings may also be used.
- On a weekly basis, measure the ulcer (to document improvement),
gently clean and debride the ulcer bed and reapply dressings.
- If the ulcer is exudative or foul smelling, this is usually due
to overgrowth by anaerobic bacteria. Put metronidazole gel 0.75%
into the ulcer bed before applying the dressing to control
- Pentoxyphylline 400 mg 3 times daily results in more rapid
healing of venous stasis ulceration.
- Venous ulcers can be very painful. Usually, the pain resolves
once a granulating base is formed. Provide adequate oral analgesia,
and monitor the severity of the pain. Often, pain reduction
parallels or precedes ulcer healing.
- After the ulcer heals, carefully continue the program of edema
control. Support hoses with at least 30 mmHg compression are
essential for all patients with healed leg ulcers.
- If the ulceration fails to heal, cultured human keratinocyte or
human skin equivalent grafting can be considered. These grafts are
not permanent, but are effective in converting nonhealing leg
ulcers into healing ones. They are also very effective in pain
- A nonhealing ulcer may be cutaneous carcinoma (basal cell,
squamous cell, etc). Biopsy nonhealing ulcerations after 3 months
- The topical antibiotics bacitracin and especially neomycin
should not be applied to leg ulcers due to the high risk for
allergic contact dermatitis.
- Oral antibiotics are overused in the management of leg ulcers.
Many "exudative" ulcers represent appropriate exudation indicative
of the early phase of wound healing. This will resolve over a few
weeks as the ulcer bed is replaced with granulation tissue.
- Any ulceration that is deep and fails to heal, or that develops
an undermined "pocket" at one edge, should be evaluated for
underlying osteomyelitis with an appropriate radiological
- If arterial insufficiency coexists (especially ABI <0.7),
vascular surgical intervention may be required before the ulcer
- Nonhealing venous insufficiency ulcerations frequently occur
after surgeries for skin cancers below the knee in elderly persons.
Before surgery in elderly persons, perform an ABI and evaluate the
patient for venous insufficiency. If significant venous
insufficiency exists, consider wrapping the extremity with a
support wrap (as outlined above) during the healing period.
- Cholesterol emboli, sickle cell disease, polyarteritis nodosa,
Buerger's disease, cocaine use, and antiphospholipid antibody
syndrome may all cause lower leg ulcerations. If the ulcer is
atypical or fails to heal, consider appropriate evaluation.