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Leg ulcers (crural ulceration)

 Causes
 Risk group
 Symptoms
 Location
 Where to seek help and advice
 Treatment
Prevention


Causes

The causes of leg ulcers are diverse, internally complex and almost exclusively of endogenous-internal origin.

Without a doubt, however, the most common cause of leg ulcers is venous hypertension and arterial insufficiency.

Other possible causes of leg ulcers:

  • hypertension: necrotising vascular dermatitis – necrotic angiodermatitis (Martorell syndrome)
  • infections: osteomyelitis, tuberculosis, pyoderma gangrenosum, leprosy, insect bites
  • vasculitis: polyarteritis nodosa, rheumatoid arthritis
  • haematological disorders: haemolytic anemia, fibrinolytic disorders
  • neurological disorders: poliomyelitis, peripheral neuropathy (diabetes)
  • cancer: mixed basisquamous carcinoma (Marjolin’s ulcer), melanoma, Kaposi’s sarcoma, lymphoma

Ooccurrence

  • 75% of all vascular ulcers are the result of venous hypertension – venous ulcers
  • 15% is generated as a result of atherosclerosis – mixed ulcers
  • 10% is arterial ulcers

Venous ulcers are caused by severely impaired activity of leg veins. In advanced venous insufficiency of the lower limbs, venous circulation in the lower limbs is disturbed and venous valves are damaged – which results in congestion and increased pressure in the veins. Valves control the blood flow so that it flows only in the direction towards the heart, not to move back. In case of damage or malfunction of valves blood flows back to the lower limb. Blood pressure in the venous system increases, which, if untreated, causes further damage to the valves and superficial veins. Walls of veins lose their flexibility and elasticity, get thicker. For the purpose of treatment and prevention of recurrence of ulcers, it is very important to identify the locations of venous insufficiency.

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Risk group

  • obesity
  • work in a seated or standing position, leading to the stagnation of blood in leg
  • hereditary factors – presence of varicose veins in parents
  • age, mostly at risk are people over 60 years of age
  • sex, statistically varicose veins are more common in women than in men
  • number of pregnancies (the more births the greater the risk of varicose veins)
  • constipation
  • flat feet
  • oral contraception
  • tallness

Symptoms

The initial phase of venous insufficiency: feeling of heavy legs, especially in the evening, the emergence of the so-called spider veins and reticular veins. The next stage in the development of the disease are: emerging swelling around the ankles, then also swelling of the entire lower leg. Initially the swelling disappears after a night rest, and then becomes constant. After some times varicose veins may occur i.e. permanent extension of superficial veins.

In advanced venous insufficiency of the lower limbs trophic skin changes appear as well as discoloration, spots and hardening. Then itching appears, bumps, cracks, skin covering varicose veins is damaged, which inevitably leads to the formation of difficult to heal wounds known as leg ulcers.

Location

  • Typical venous ulcers are located above the medial malleolus leg.
  • Ischemic ulcers (arterial) are often found on the back of the toes, on the heel, or on the front surface of the shin.
  • Rheumatic ulcers usually involve the side and back surface of the rest of the lower leg and the ankle area.

Where to seek help and advice

Of course, in the first instance go to your GP who should refer you to a specialist surgeon. Currently, the best method of diagnosing venous insufficiency is to perform an Colour Doppler ultrasound test.

Treatment

In case of ulcers resulting from advanced chronic venous insufficiency, leg swelling, not treated varicose veins, it is a standard to conduct a multidirectional model of treatment comprising of:

  • local treatment of the wound – treatment by means of dressings,
  • compression therapy – treatment with special bandages or stockings,
  • drug therapy – treatment with pharmaceuticals – medicines,
  • and ultimately the elimination of venous reflux – surgical treatment.

The local treatment is to accelerate the cleansing of the ulcer from necrotic tissue and stimulation of the healing process. The purpose of the conservative treatment is to reverse the effects of venous hypertension, improving venous return, and thus – reducing the swelling. The basis of the conservative treatment is the compression therapy. It increases local hydrostatic pressure and reduces pressure in superficial veins, reducing the transudation of fluid from the blood. Gradual compression accelerates blood flow in the veins of the deep system. An extremely important element of the conservative treatment is the pharmacotherapy.

The treatment of leg ulcers is tough and long-lasting, so to make it the least expensive and effective it must be based on genuine and systematic cooperation with a healthcare professional.

Prevention

Factors which a person can control are WEIGHT and LIFESTYLE.

 WEIGHT:

  • losing excess weight

LIFESTYLE:

  • increasing physical activity especially walking, cycling, swimming. This activities the so-called „calf pump”. Muscle contractions stimulate the venous circulation, pushing blood to the heart – blood does not stop in the veins.
  • taking care of yourself in the workplace, especially when staying seated – footrests, avoid staying long in one position without moving or standing. Involving exercises allowing the calf muscles to work – for example, march in place in an upright position, bending towards the foot being in a sitting position.

Once microcirculatory disturbances occur, they can be corrected through the use of compression products:

  • knee-socks
  • stockings
  • anti-varicose tights

and involve medical treatment – always preceded by consultation with your doctor or a pharmacist.