The Wound Healing Society estimates that around 15% of the geriatric population in the United States suffers from chronic wounds. Moreover, it’s observed that almost 10% of the population will develop a chronic wound and around 2.5% will die from it. It’s worth noting that most of these wounds are chronic wound ulcers that are related to chronic venous insufficiency.
So how long does it take to develop a lower extremity ulcer in chronic venous insufficiency? A lower extremity ulcer or chronic leg ulcer is a non-healing wound that lasts even 3 to 12 months after the provision of appropriate treatment. It can form years after the occurrence of a venous disease although it may also occur suddenly.
How A Lower Extremity Ulcer Is Formed
Incompetent valves and high pressure in the blood vessels that result in the pooling of blood in the venous circulatory system are pointed as possible reasons behind chronic ulcer formation. Different ulcer types like venous ulcer, arterial ulcer, neuropathic or diabetic ulcer, and pressure ulcer also have different hypotheses as to the specificities of their mechanisms and differences in their clinical presentation.
1) Venous Ulcer
Venous ulcer or venous stasis ulcer is the most common type of chronic ulcer, accounting for 70% of cases of chronic leg ulceration. It appears as a shallow, painful ulcer on bony prominences of the lower extremities, particularly the gaiter area (the area above the medial malleolus).
It’s an ulcer type characterized by periods of exacerbation and remission. Venous ulcer healing also takes a long time, adversely affecting the quality of life of the individual experiencing this venous disorder.
Three theories are formulated as to the development of venous leg ulceration:
- Fibrin cuff theory – In this theory, it’s speculated that venous leg ulcer arises as a result of the leakage of fibrinogen from capillaries due to chronic venous compromise. Fibrinogen hardens upon leakage, forming a fibrin cuff that surrounds the capillaries. Oxygen and nutrients won’t reach the skin and its superficial vein as a result of poor blood flow due to the formation of this fibrin cuff which then results in ulceration.
- Leukocyte entrapment theory – High blood pressure in the veins results in a decreased pressure gradient between the arteriolar (the end that’s supposedly higher in pressure) than the venular end of the capillaries. Because of this, blood flow is slower within the capillaries, which in turn leads to more blood cells sticking to the endothelium (the lining of the blood vessels). Worsening of the poor oxygenation is then caused by the inflammatory mediators (ICAM-1, VCAM-1) and reactive oxygen species, ultimately leading to venous ulceration.
- Microangiopathy theory – According to this theory, chronic ulceration results from the impaired nutrition and oxygenation of the skin due to the formation of microthrombi that occlude capillaries or the capillaries presenting with long intracapillary stasis.
2) Arterial Ulcer
Arterial leg ulcers or ischemic leg ulcers are deep ulcers over bony prominences characterized by round or punched wounds with sharply demarcated borders, with areas of yellowing or necrosis (dead tissues), and exposure of tendons.
It occurs mainly due to tissue and arterial insufficiency in blood flow and oxygen. Other findings to help in its correct diagnosis include impairment in the pulses that may be palpated in the lower extremities, cool limbs, femoral bruit, and prolonged venous filling time.
Three mechanisms are also hypothesized to cause arterial leg ulcers and these include:
- Extramural strangulation – Strangulation of the arterioles may be caused by different conditions amongst adults which include scar tissue and radiodermatitis. These conditions cause fibrotic bands to develop around the arterioles which causes the occlusion to occur.
- Mural thickening or accretion of intimal plaques in an arterial disease like atherosclerosis – This mechanism may lead to the formation of atherothrombosis, embolism, or signs of infection.
- Intramural restriction of blood flow – Occlusion of small blood vessels may occur by making the blood more viscous or increasing the occurrence of adhesion of the platelets, ultimately leading to chronic ulceration.
3) Neuropathic Ulcer
Neuropathic ulcer is a condition commonly observed in the soles of the feet of patients with diabetes mellitus, neurologic disorders, or Hansen disease. It’s a condition that affects 15% of all diabetic individuals, brought by multiple factors such as peripheral neuropathy and ischemia from peripheral vascular disease, trauma, among others.
4) Pressure Ulcer
Pressure ulcers are chronic wounds over bony prominences brought by tissue ischemia and necrosis brought by unrelieved pressure. Primary risk factors for pressure ulcers include limited mobility, excessive moisture, and altered mental status. It’s also estimated that 70% of older patients experience pressure ulcers that can give rise to drastic complications including septicemia, osteomyelitis, and even death.
5) Other Causes Of Chronic Ulceration
Other medical conditions that may predispose a patient to chronic ulceration, aside from those previously mentioned include:
- Hematologic disorders such as sickle cell disease, thalassemia, and other hemolytic anemias due to occlusion of microcirculation
- Infections, commonly a bacterial infection, including bacterial synergistic gangrene, primary uncomplicated streptococcal ulcer, and tuberculous cutaneous ulcer
- Hypertensive ulcer
- Ulceration secondary to dermatitis artefacta (production of self-inflicted wounds due to psychological conditions)
- Pyoderma gangrenosum
How Venous Ulcers Are Treated
The goals of treatment for the treatment modalities available for chronic ulceration include reduction of edema (swelling due to fluid build-up), wound repair and regeneration for the ulceration, and reduction of the possibility of the rate of recurrence of the ulcer.
It should be noted, however, that despite the variety of the treatment methods available (this includes conservative management, mechanical treatment, medications, and surgical procedures), the healing benefit from these procedures varies and very few studies support their use.
1) Conservative Management
Leg elevation in combination with compression therapy and the use of dressings under compression bandages are considered under conservative management.
- Leg elevation – Leg elevation entails raising the lower extremities above the level of the heart, optimally performed for 30 minutes, 3 to 4 times a day. As evidence of its efficacy, it’s worth noting that in a study of patients with lipodermatosclerosis caused by chronic venous insufficiency, it was observed that microcirculatory blood flow was increased by 45%.
- Use of dressings – Despite the wide range of dressings available, including hydrocolloids, foams, hydrogels, and others, no data support the difference in the efficacy of these types of dressings. More expensive dressings also don’t have a significant advantage over less expensive dressings. Because of these, the use of dressings may depend on cost, ease of use, and the preference of patient and physician.
2) Medications
The addition of medications in combination with compression therapy and other treatment modalities is done to improve the overall healing benefits of the procedures being undergone. In general, these medications work by reducing blood viscosity through inhibition of platelet aggregation and preventing inflammation and bacterial infection. Common medications and therapies used include:
- Pentoxifylline
- Aspirin (a blood thinner)
- Iloprost
- Oral zinc
- Antibiotics/antiseptics
- Hyperbaric oxygen therapy
3) Surgical Treatment
Surgical treatment should be considered to help reduce the rate of ulcer recurrence in patients that aren’t responsive to conservative therapy. Surgical procedures that patients with refractory ulceration include:
- Debridement – Debridement entails the removal of necrotic (dead tissue) and infections that may be done through sharp, enzymatic, mechanical, biologic (through the use of larvae), or autolytic means. This procedure is best done on arterial insufficiency rather than venous insufficiency.
- Skin grafting – For individuals with large or recurring ulcers, human skin grafting may be done through autograft (skin is taken from other body parts of the same individual), allograft (skin is taken from another person), or artificial (engineered products of human skin equivalent). Before undergoing this process, however, the edema and the underlying condition associated with the ulceration should first be addressed.
Vein Center Doctor: Offering Excellent Outpatient Vein Treatments
Medical management for chronic leg ulcers isn’t enough. There’s a high chance of venous ulcer recurrence unless the underlying causes such as deep venous thrombosis, varicose veins, and obesity may be addressed.
As such, it’s best to go to trusted outpatient vein treatments such as those that Vein Center Doctor can offer to help manage the vascular disease that might have been the reason behind the chronic leg ulcer. The outpatient vein treatments available at Vein Center Doctor include:
1) Radiofrequency Ablation
Radiofrequency ablation or thermal ablation is a minimally invasive, FDA-approved procedure. It involves stripping veins to prevent saphenous vein reflux. It’s an image-guided procedure that requires only local anesthesia and radiofrequency catheters where heat is used to destroy the endothelium (inner layer) of the vein.
This procedure, however, can’t be undergone by individuals with an incompetent superficial vein diameter of less than 2 mm, medical history of deep vein thrombosis, prior surgery of endovenous treatment of the same leg, pregnancy, and known malignancy.
2) Endovenous Laser Treatment
Like radiofrequency ablation, endovenous laser treatment is also an image-guided procedure that uses Doppler ultrasound. It also uses heat, but it comes from laser fiber inserted into a catheter in order to close enlarged veins. This process can also shrink the veins through the formation of scar tissue within the blood vessel.
The direction of blood flow will then be transferred to other blood vessels. No stitches will be needed although the area will be covered with bandages. Side effects include bruising that lasts only up to 2 weeks. Very rare ones are nerve damage and blood clots, but these only happen in the hands of poorly-trained practitioners.
3) Sclerotherapy
This therapy is used for varicose veins and “spider veins”. A salt solution will be injected through a very fine needle directly over the area of concern to irritate the endothelium, causing the blood vessel to shrink and for the blood to clot. This procedure typically lasts for approximately 15 to 30 minutes.
Meanwhile, the number of veins injected with the solution is based on the size and location of veins and the condition of the patient. Some side effects include reactions associated with injection such as raised, red areas, bruising, and itching at the injection site that will resolve on their own eventually.
4) VenaSeal
The VenaSeal closure system is a superficial vein therapy against venous reflux that uses no heat and doesn’t require the use of anesthesia and compression stockings. This minimally invasive procedure has relatively fewer side effects compared to other treatments.
In terms of amount, 0.1 cc of the VenaSeal adhesive is first delivered every 3 cm intervals by the dispensing unit for 3 seconds followed by compressing the area for 3 minutes.
5) Compression Therapy
Compression therapy is the standard of care for individuals with chronic venous insufficiency. Types include elastic compression therapy, inelastic compression therapy, and intermittent pneumatic compression.
Aside from its application in chronic venous insufficiency, the use of compression stockings is also the standard of care for venous ulcers, backed by evidence that the rate of healing is faster with compression therapy than without.
Its lifelong use helps decrease the rate of recurrence of ulcer but its use is limited by factors such as pain and application difficulty. However, it can’t be used by individuals with arterial disease and uncompensated heart failure.
Get The Best Outpatient Vein Treatments At Vein Center Doctor
It takes years before a lower extremity ulcer develops, although it may also occur all of a sudden. Venous ulcer treatment only can go as far as managing the wound and ulcer formation may recur when the underlying causes aren’t addressed such as deep vein involvement.
At Vein Center Doctor, we help in the prevention and management of leg ulcers by addressing them down to their underlying causes. We’re experts in managing non-functional and damaged veins and other diseases associated with blood vessels. For healthier leg veins, contact us today at 862-227-1143 (NJ) or 862-227-1054 (NY).
