This study was presented at 2022 The Wound Meeting on March 26, 2022.
Defined as an ulceration in a lower extremity caused by venous hypertension, venous ulcers are a common condition which are known to affect approximately 1% of the population. They cause substantial socioeconomic burden and significant impact on patients’ quality of life. Although a number of diagnostic procedures are applicable in diagnosis of venous ulcers, color-flow duplex ultrasound remains the gold standard. For therapeutic options, compression therapy remains the mainstay. Adjunct therapies such as physiotherapy, manual lymphatic drainage, or phlebotonics can be considered to provide symptomatic relieve. This article aims to provide an overview of the anatomy and pathophysiology of venous ulcers as well as their conservative treatment.
Venous ulcers are open skin wounds occurring in regions of the leg or foot affected by venous hypertension [
The prevalence of venous ulcers ranges from 0.7% to 2% of the general population [
An understanding of venous anatomy provides a better comprehension of chronic venous disease. The venous structure of the lower extremities can be categorized into superficial and deep systems. Superficial veins (e.g., greater saphenous vein, lesser saphenous vein and accessory saphenous vein) are located between the dermis and the muscle fascia, whereas deep veins (e.g., femoral vein, common femoral vein, deep femoral vein, popliteal vein, anterior and posterior tibial vein) are located beneath the muscle fascia [
Conductivity, capacitance, and directionality are the major components of venous physiology. Conductivity is related to low resistance in venous structures. This feature enables trans-portation of a large volume of blood without high energy ex-penditure. Capacitance refers to how easily the vein wall di-lates. Directionality is enabled by one-way valves in the venous structure generated from three physiological functions: respi-ration, cardiac contraction and locomotion. Venous dysfunction is induced from alteration of any of these three components.
A constant unidirectional flow from the superficial into the deep venous system is ensured by competent valves in perforating veins. Superficial veins also must have competent valves to propagate flow into the more proximal deep veins. With incompetent valves, retrograde displacement of blood into the intramuscular veins and sinusoids can occur. This causes im-pediment of arterial inflow and decrease of muscle pump effectiveness (
Illustration of incompetent valves resulting in venous reflex. With competent valves, venous blood flows physiologically from the superficial system to the deep system through perforating veins (left). When damaged valves lose their function, reflux occurs which ultimately leads to venous hypertension (right).
Obstruction is an important factor in the pathogenesis of venous ulcers. Proximal venous obstruction has a higher prevalence in chronic venous disease and implies poorer outcomes in treatment [
The theory of the calf muscle pump concept is a crucial com-ponent of venous physiology. Contraction of the calf muscles causes compression of the deep venous system, resulting in proximal propagation of blood. On the other hand, relaxation of the calf muscles causes expansion of the deep venous system followed by influx of blood from the superficial venous system through perforating veins. Dysfunctional calf muscles could be the prime cause for venous hypertension in some patients. Decreased ankle range of motion is also frequently observed in people with venous ulcers. Patients with chronic venous disease are prone to secondary lymphedema (phlebo-lymphedema) which is usually more severe at the ankle level. Because of restrictions in ankle motion, the effectiveness of the calf muscle pump decreases.
Genetic mutation can be a predisposing factor for developing venous ulcers. Factor XIII is an important element for the for-mation of a fibrin matrix wound cover, further initiating a cascade of fibroblast growth and migration. Mutation in the
Introduced in 1917 by Homans [
Blalock [
Proposed by Burnand et al. [
Early activation of white blood cells resulting from venous hypertension has been demonstrated in previous studies. Coleridge Smith et al. [
The CEAP (Clinical-Etiological-Anatomical-Pathophysiologi-cal) classification is the current international standard for clas-sifying chronic venous disease [
CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification for chronic venous disease
Clinical | Etiology | Anatomy | Pathophysiology |
---|---|---|---|
C0 No visible abnormalities | Ep Primary | As Superficial | Pr Reflux |
C1 Telangiectasis or reticular veins | Es Secondary | Ap Perforating | Po Obstruction |
C2 Varices | Ec Congenital | Ad Deep | Pr,o Reflux and obstruction |
C3 Edema | En No venous cause identified | An No venous location identified | Pn No venous pathophysiology identified |
C4 Changes in skin and subcutaneous tissue | |||
a. Pigmentation or eczema | |||
b. Lipodermatosclerosis or atrophie blanche | |||
C5 Healed ulcer | |||
C6 Active, open ulcer | |||
S Symptomatic | |||
Pain, tightness, skin irrigation, heaviness, muscle cramp | |||
A Asymptomatic |
The diagnosis of venous ulcers is clinically based on patient history and clinical presentation, augmented when necessary by diagnostic tests. While color-flow duplex ultrasound is currently the gold standard diagnostic procedure for chronic venous disease [
The ankle-brachial index (ABI) is a non-invasive test which identifies peripheral arterial disease (PAD) in the lower extremity. If the ABI is less than 0.8, it is mandatory to evaluate and rule out arterial insufficiency because application of compression therapy in such instances can cause detrimental con-sequences.
Duplex ultrasound is a non-invasive examination which combines traditional ultrasound with Doppler ultrasonogra-phy for structural and functional evaluation of the venous system. Both arterial and venous blood flow can be visualized, with easy detection of obstructions and refluxes [
Photoplethysmography (also called light reflex rheography), also non-invasive, is a test which measures venous refill time. A probe is positioned on the skin just above the ankle, and the patient is instructed to perform brief periods of calf muscle pump exercises. Infrared light reflected by hemoglobin is mea-sured by the probe, assessing skin blood flow reduction caused by exercise [
Other imaging modalities such as computed tomography and magnetic resonance imaging can also be utilized. Although not routinely used for venous imaging, they can be used for evaluation of pelvic vein thrombosis due to the diagnostic limitations of duplex ultrasound in intrapelvic structures.
The goal of venous ulcer treatment is to improve symptoms, prevent sequelae, and promote ulcer healing. Compression therapy and ancillary treatment (e.g., physical therapy, manual lymphatic drainage, and phlebotonics) constitute the back-bone of non-surgical venous ulcer treatment.
The cornerstone of treatment for venous ulcers is medical compression therapy. While being both easy to apply and non-invasive, compression therapy effectively counteracts the mechanism of chronic venous disease (e.g., venous reflux and hypertension); therefore, the importance of compression can never be overstated. The following are examples of medical compression therapy: (1) short-stretch bandages, (2) long-stretch bandages, (3) Non-elastic bandages, (4) multicomponent systems, (5) ulcer stocking systems, and (6) adaptive compression systems.
Systems for compression therapy
Type | Example | Self-application | Indication | Advantage | Disadvantage | Stiffness |
---|---|---|---|---|---|---|
Short-stretch bandages | Comprilan | No | Decongestion phase | High working pressure | Slipping | High |
Washable and reusable | ||||||
Long-stretch bandages | Perfekta | Yes | Decongestion phase | Easy application | Low working pressure | Low |
Removed over night | ||||||
Non-elastic bandages | Zinc paste (Unna) | No | Decongestion phase | High working pressure | Messy | Very high |
Well tolerated during rest | ||||||
Multicomponent system | Coban 2, UrgoK2 | No | Decongestion phase and maintenance phase | High working pressure Well tolerated during rest | Bulky | High |
Ulcer stocking system | Jobst UlcerCare | Yes | Maintenance phase | Patient can shower and self-manage | Difficult donning | Moderate |
Adaptive compression bandages | Actitouch | Yes | Decongestion phase and maintenance phase | Pressure is sustained Patient can shower and self-manage | Difficult donning | High |
Modified from Partsch. Phlebology 2014;29(1 suppl):140-5, with permission of SAGE Publications [
Short-stretch bandages have low elasticity (less than 100%). They are usually made of cotton and can provide high working and low resting pressures. A padding layer should preferably be used to prevent slippage (
Compression method using short-stretch bandages. (A) Materials, (B) tubular gauze, (C) underpadding, and (D) short-stretch bandage application with 50% overlap are displayed.
Long-stretch bandages are composed of cotton, polyamide, elastane and viscose. Because of their high elasticity (more than 100%), long-stretch bandages can provide low working and high resting pressures. As this can lead to pressure injury, using long-stretch bandages exclusively for strong compression is not recommended and overnight application should be avoided [
Non-elastic bandages such as zinc paste bandages (used in Unna boots) are notable for their very high working pressures and very low resting pressures. Their elasticity is below 10%. Zinc paste bandages consist of elastic fabric drenched in zinc solution or zinc paste. After wrapping the wet bandages around the affected extremity, compression pressure is devel-oped through solidification. The dried bandage becomes rigid and is maintained for several days [
Multicomponent systems commonly called “four-layer ban-dages” consist of different materials, including padding, compression, and fixation bandages. They provide great tolerability and a visual indicator assists in achieving optimal pressure [
Ulcer stocking systems are usually made of two components: an understocking and an outer compression stocking. After training, many patients can readily apply them on their own (
Compression method using ulcer stocking systems. (A) Material, (B) tubular gauze, and (C) ulcer stocking application are displayed.
Adaptive compression systems are also known as wrap systems or Velcro systems. These consist of short stretch material fixed by Velcro bands. Pressure can be adjusted at need to a comfortable level by the patient [
To properly understand the effects of compression therapy, one must know the distinction between resting and working pressure (
Illustration of comparison between resting and working pressure. Resting pressure refers to constant external pressure applied to skin and venous systems generated by the pressure garment (left). Working pressure refers to a dynamic pressure exerted on skin and venous systems generated from the combination of muscle contraction forces and the pressure garment (right).
Compression should be adjusted according to treatment stage, which can be divided into the decongestion phase and the maintenance phase. Edema control and promotion of ulcer healing are the primary aims in the decongestion phase. In this period strong compression methods, such as short-stretch bandages or multicomponent bandages, can be applied. Because of profuse edema and discharge, a combination of high absorbent wound dressings with daily renewal of bandages is generally recommended. Over time, decrease in exudate and congestion will allow twice-weekly bandage changes [
There is no clear evidence that proves superiority of a par-ticular type of compression. Regardless of the bandage type, it must be properly applied, which requires training [
Some critical contraindications should be considered before applying compression therapy [
The goal of physiotherapy is to decrease venous pressure and edema by increasing calf muscle pump function through exercise or biomechanical stimulation. Lifestyle changes and spe-cial exercises can help in improving both calf muscle function and ankle mobility. Klyscz et al. [
Manual lymphatic drainage by massaging is a well-established therapy for lymphedema patients. This method increases both the transport capacity of the lymphatics and peripheral circu-lation [
Drugs such as natural flavonoids (e.g., rutoside, French mari-time pine bark extract, grape seed extract, etc.) and similar synthetic products (e.g., calcium dobesilate, naftazone, amin-aftone, chromocarbe) which are known to improve blood cir-culation are collectively referred to as venoactive drugs or phlebotonics. These agents are used to relieve symptoms such as pain, paresthesia, or restless leg but have no reported effect on ulcer healing [
Matrix metalloproteinases play a critical role in venous ulcer pathophysiology. Imbalance between proteinase activity and inhibition is a major cause of delayed wound healing in venous ulcers [
Venous ulcers are a common condition caused by venous reflux and obstruction ultimately resulting in venous hypertension. Numerous theories have been proposed to explain the pathogenesis of venous hypertension causing ulceration from structural to molecular levels. Based on CEAP classification, venous ulcers are clinically diagnosed, but color-flow duplex ultrasound remains the gold standard of all diagnostic modalities. Although a wide range of therapeutic options exist, compression therapy is the fundamental principle that can be applied in all disease stages. Adjunct therapies such as physiotherapy, manual lymphatic drainage, and phlebotonics can be considered to provide symptomatic relief.
No potential conflict of interest relevant to this article was reported.