History
A 73-year-old retired dinner lady presents with a 4-week history of a non-healing area on her right leg following trauma from a shopping trolley. She tells you that she has ‘suffered from her legs’ for many years now, complaining of long-standing swelling, ach-ing and itching of her lower legs, particularly towards the end of the day. She is a non-smoker. She has six children. She mentions that her own mother had leg ulcers which never healed. Her only medication is bendroflumethiazide 2.5 mg/day.
Examination
She is overweight (height 1.55 m, weight 78 kg), her blood pressure is 130/70 mmHg, and urine dipstick is negative. There is an irregularly shaped ulcer over the medial malleolus on the right leg (Fig. 48.1). It measures 6.5 4 cm at maximum diameter. The surface of the ulcer has some clean adherent slough and the base shows evidence of granulation tissue, the edges of the ulcer are sloping. The surrounding skin is red-brown colour, it is noticeably shiny and feels tight. Her dorsalis pedis pulses are easily palpable bilaterally. The remainder of her examination is unremarkable.
Questions
• What is the diagnosis?
• What risk factors does the patient have for this condition?
• How should she be investigated and managed?
Medicine
This clinical presentation would fit best with venous ulcer disease. Venous ulcers are classically found in the gaiter area and may, as in this case, occur on the background of chronic venous dermatitis with consequent lipodermatosclerosis. Lipodermatosclerosis refers to the fibrosis of subcutaneous adipose tissues and is usually accompanied by haemosiderin deposition, erythema, pruritus and trophic changes of the skin. Its presence further impairs wound healing. There may be varicosities and oedema. Preceding venous hypertension may be associated with rather non-specific symptoms.
In general the diagnosis of venous ulcer disease is a clinical one based on clinical findings and demonstration of adequate pedal pulses to rule out an element of arterial insufficiency. Where secondary infection is suspected, microbiology swabs should be obtained. A recent expert consensus paper suggests that all patients with venous ulcer should undergo duplex ultrasonography to confirm or exclude venous dysfunction and identify whether the problem is caused by anatomical obstruction, reflux, or both. It is also standard practice to document ankle/brachial index prior to application of compression.
The goals of management are to control symptoms, promote healing and prevent recur-rence. A non-surgical approach remains the primary treatment. Bed-rest and elevation is effective but for most impractical, and compression is the ‘gold standard’. Compression garments or dressings can be painful and are frequently itchy. The mean time to ulcer healing, even with strict adherence to treatment, is in excess of five months. Surgical intervention to address perforator vein incompetence does not seem to alter outcome but may help to prevent recurrence; there is no effective surgical intervention to address deep venous insufficiency. There are no drugs that promote healing and, in particular, routine use of systemic antibiotics is not indicated.
KEY POINTS
• Venous disease is the most common cause of leg ulcers.
• Symptoms of venous hypertension include aching, a sense of swelling or heaviness, cramps, itch, tingling and restlessness, often worse at the end of the day or after prolonged standing.
• In addition to ulceration at the gaiter area, signs of venous hypertension include varicosities, broken reticulate capillaries, oedema, hyperpigmentation associated with haemosiderin deposition, erythema, loss of hair, or thickened trophic nail changes and ultimately lipodermatosclerosis.
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