An ulcer is a break in the skin which fails to heal. If it is not healed within 6 weeks, then it is a chronic ulcer. There are many causes of ulcers, but in Australia approximately 80% of ulcers that occur on the leg, are venous (in other words, caused by problems with the veins). The remaining 20% is made up of ulcers related to skin cancer, infections, injuries etc.
What are venous ulcers and why do they develop?
They are caused by high pressure in the veins of the leg. The high pressure is related to:
- Valve problems in the veins just under the skin (superficial system). This may be associated with varicose veins
- Valve problems in the veins running through the muscles (deep system). This can happen following a DVT (deep venous thrombosis)
- Veins in the pelvis being squashed (or compressed)
- Obesity makes it more difficult for blood to flow back to the heart from the legs
- Pregnancy leads to hormonal changes which alters the efficiency of the valves; as well as the foetus causing some mechanical obstruction of the flow
What problems can they cause?
The valves are designed to ensure good flow out of the leg back to the heart. If these valves are not working, the return of blood out of the leg is made more difficult. High-pressure in the venous system alters the way the blood runs through the skin leading to problems such as leg swelling. The skin problems include eczema, pigmentation, staining, itching and scarring in the fat layer called lipodermatosclerosis (LDS). They can bleed and minor injury such as a bump will cause an ulcer. They can be very difficult to heal and may persist for many months if not years. Chronic leg ulcers are common and become more frequent with increasing age.
How can they be treated?
Treatment is by fixing the cause, determined by investigation using ultrasound (like that used during pregnancy). It is called a venous duplex scan. It should be done by a trained vascular technologist. Occasionally a dye test is needed (venogram).
If the cause is the superficial veins (varicose veins), then they need to be treated. If the deep system is the issue, then compression using bandages or stockings is the most effective treatment. If the pelvic veins are compressed, then that can also be treated. The cause may be a combination of the above. Each needs to be addressed. If obesity is an issue, then weight loss is strongly advised.
Antibiotics should only be used if there is clear evidence of cellulitis (infection of the surrounding skin). The key is compression in association with treatment of associated varicose veins.
Can they be cured?
They can only be cured if the cause is treated completely, and if the skin has not been so damaged that it cannot recover. If the cause if purely from varicose veins, and if they are treated completely, then yes, one can cure a venous ulcer. Unfortunately the skin does not always recover completely, so it remains vulnerable and may break down with a minor injury. The deep system is very difficult to cure.
There are some things you can do to decrease the chances of developing one. Prompt and aggressive management of a DVT has been shown to decrease the chance of damage to the deep valves. Early treatment of varicose veins especially if there is any evidence of significantly raised pressure such as pigmentation, staining, eczema, itching, swelling etc. Good quality Class II compression (25-35mmHg) in people with a history of DVT or who have the signs of the above can also be helpful.