Stasis ulcer: Difference between revisions
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{{SK}} Venous insufficiency ulceration, stasis ulcer, stasis dermatitis, varicose ulcer, ulcus cruris. | |||
==Overview== | ==Overview== | ||
Latest revision as of 21:12, 7 October 2014
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Jesus Rosario Hernandez, M.D. [2].
Synonyms and keywords: Venous insufficiency ulceration, stasis ulcer, stasis dermatitis, varicose ulcer, ulcus cruris.
Overview
Venous ulcers (venous insufficiency ulceration, stasis ulcers, stasis dermatitis, varicose ulcers, or ulcus cruris) are wounds that are thought to occur due to improper functioning of venous valves, usually of the legs (hence leg ulcers).[1]:846 They are the major occurrence of chronic wounds, occurring in 70% to 90% of leg ulcer cases.[2] Venous ulcers develop mostly along the medial distal leg, and can be very painful.
Two layers of skin created from animal sources as a skin graft has been found to be useful in venous leg ulcers.[3]
Pathophysiology
The exact etiology of venous ulcers is not certain, but they are thought to arise when venous valves that exist to prevent backflow of blood do not function properly, causing the pressure in veins to increase.[4][5][6][7] The body needs the pressure gradient between arteries and veins in order for the heart to pump blood forward through arteries and into veins. When venous hypertension exists, arteries no longer have significantly higher pressure than veins, and blood is not pumped as effectively into or out of the area.[4][5][6][7]
Venous hypertension may also stretch veins and allow blood proteins to leak into the extravascular space, isolating extracellular matrix (ECM) molecules and growth factors, preventing them from helping to heal the wound.[4][7] Leakage of fibrinogen from veins as well as deficiencies in fibrinolysis may also cause fibrin to build up around the vessels, preventing oxygen and nutrients from reaching cells.[4] Venous insufficiency may also cause white blood cells (leukocytes) to accumulate in small blood vessels, releasing inflammatory factors and reactive oxygen species (ROS, free radicals) and further contributing to chronic wound formation.[4][7] Buildup of white blood cells in small blood vessels may also plug the vessels, further contributing to ischemia.[8] This blockage of blood vessels by leukocytes may be responsible for the "no reflow phenomenon," in which ischemic tissue is never fully reperfused.[8] Allowing blood to flow back into the limb, for example by elevating it, is necessary but also contributes to reperfusion injury.[5] Other comorbidities may also be the root cause of venous ulcers.[6]
It is in the crus that the classic venous stasis ulcer occurs. Venous stasis results from damage to the vein valvular system in the lower extremity and in extreme cases allows the pressure in the veins to be higher than the pressure in the arteries. This pressure results in transudation of inflammatory mediators into the subcutaneous tissues of the lower extremity and subsequent breakdown of the tissue including the skin.
Wounds of the distal lower extremities arising from causes not directly related to venous insufficiency (e.g., scratch, bite, burn, or surgical incision) may ultimately fail to heal if underlying (often undiagnosed) venous disease is not properly addressed.
Characteristics
Edema and fibrinous exudate leads to fibrosis of subcutaneous tissues with localized pigment loss and dilation of capillary loops. This is called atrophic blanche. This can occur around ankles and gives an appearance of inverted champagne bottle to legs. Large ulcers may encircle the leg. Lymphoedema results from obliteration of superficial lymphatics. There is hypertrophy of overlying epidermis giving polypoid appearance, known as lipodermatosclerosis.
Physical examination
Gallery
Head
Diagnosis
Classification
A clinical severity score has been developed to assess chronic venous ulcers. It is based on the CEAP (clinical, etiology, anatomy, and pathophysiology) classification system developed by an expert panel. A high score gives a poor prognosis.[9]
Distinction from arterial ulcer
An arterial ulcer tends to occur on lateral side of distal leg and leg is pulseless and cool. Venous ulceration is typically seen just above the medial malleolus. Arterial ulcers are seen distally and over bony prominences.
Treatment
The main aim of the treatment is to create such an environment that allows skin to grow across an ulcer. In the majority of cases this requires finding and treating underlying venous reflux and NICE (National Institute for Health and Care Excellence) Clinical Guidelines CG 168 recommend referral to a Vascular Service for anyone with a leg ulcer that has not healed within 2 weeks or anyone with a healed leg ulcer.[10]
Bisgaard regimen
Most venous ulcers respond to a regimen called Bisgaard regimen for treating ulcers.[11] It has four components: Patient education, elevation of foot, elastic compression and evaluation.
Compression therapy
Non-elastic, ambulatory, below knee (BK) compression aggressively counters the impact of reflux on venous pump failure. Compression therapy is used for venous leg ulcers and can decrease blood vessel diameter and pressure, which increases their effectiveness, preventing blood from flowing backwards.[4] Compression is also used [4][12] to decrease release of inflammatory cytokines, lower the amount of fluid leaking from capillaries and therefore prevent swelling, and prevent clotting by decreasing activation of thrombin and increasing that of plasmin.[2] Compression is applied using elastic bandages or boots specifically designed for the purpose.[4]
Regarding effectiveness, compression dressings improve healing.[13] It is not clear whether non-elastic systems are better than a multilayer elastic system.[13] Patients should wear as much compression as is comfortable.[14] The type of dressing applied beneath the compression does not seem to matter, and hydrocolloid is not better than simple low adherent dressings.[15][16] Recently there have been clinical studies on a multi-functional botanical-based ointment in combination with compression therapy in the treatment of difficult-to-heal wounds, including venous leg ulcers.[17]
Intermittent pneumatic compression devices may be used, but it is not clear that they are superior to simple compression dressings.[18]
Pentoxifylline
A meta-analysis of randomized controlled trials by the Cochrane Collaboration found that "Pentoxifylline is an effective adjunct to compression bandaging for treating venous ulcers and may be effective in the absence of compression".[19] It works by reducing platelet aggregation and thrombus formation.
Artificial skin
Artificial skin, made of collagen and cultured skin cells, is also used to cover venous ulcers and excrete growth factors to help them heal.[20] A Systematic review of 17 Randomized trials found that Bilayer Artificial Skin with compression bandaging is useful in the healing of venous ulcers when compared to simple dressings.[3]
Surgical correction of superficial venous reflux
A randomized controlled trial found that surgery "reduces the recurrence of ulcers at four years and results in a greater proportion of ulcer free time".[21]
Local Anaesthetic Endovenous correction of superficial venous reflux
Local anaesthetic endovenous surgery using the thermoablation (endovenous laser ablation or radiofrequency), perforator closure (TRLOP) and foam sclerotherapy showed an 85% success rate of healing, with no recurrence of healed ulcers at an average of 3.1 years, and a clinical improvement in 98% in a selected group of venous leg ulcers.[22]
TIRS Technique
Terminal Interruption of Reflux Source Technique entails blocking off the veins that drain the ulcer bed using Sotradecol or Polidocanol foam, administered by ultrasound guidance.[23]
Prognosis
Venous ulcers are costly to treat, and there is a significant chance that they will recur after healing;[2][4] one study found that up to 48% of venous ulcers had recurred by the fifth year after healing.[4] However treatment with local anaesthetic endovenous techniques suggests a reduction of this high recurrence rate is possible.[22]
Without proper care, the ulcer may get infected leading to cellulitis or gangrene and eventually may need amputation of the part of limb in future.
Some topical drugs used to treat venous ulcer may cause venous eczema.[24]
Current research
The current ‘best’ practice in the UK is to treat the underlying venous reflux once an ulcer has healed. It is questionable as to whether endovenous treatment should be offered before ulcer healing, as current evidence would not support this approach as standard care. EVRA (Early Venous Reflux Ablation) ulcer trial - A UK NIHR HTA funded randomised clinical trial to compare early versus delayed endovenous treatment of superficial venous reflux in patients with chronic venous ulceration opened for recruitment in October 2013. The study hopes to show an increase in healing rates from 60% to 75% at 24 weeks.[25]
Research from the University of Surrey and funded by the Leg Ulcer Charity is currently looking at the effects that having a leg ulcer has on the relatives and friends of the affected person - and how this changes if the ulcer is permanently cured by endovenous surgery.[26]
References
- ↑ James, William D.; Berger, Timothy G.; et al. (2006). Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. ISBN 0-7216-2921-0.
- ↑ 2.0 2.1 2.2 Snyder RJ (2005). "Treatment of nonhealing ulcers with allografts". Clin. Dermatol. 23 (4): 388–95. doi:10.1016/j.clindermatol.2004.07.020. PMID 16023934.
- ↑ 3.0 3.1 Jones, JE; Nelson, EA; Al-Hity, A (Jan 31, 2013). "Skin grafting for venous leg ulcers". The Cochrane database of systematic reviews. 1: CD001737. PMID 23440784.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 Brem H, Kirsner RS, Falanga V (2004). "Protocol for the successful non-surgical treatment of venous ulcers". Am. J. Surg. 188 (1A Suppl): 1–8. doi:10.1016/S0002-9610(03)00284-8. PMID 15223495.
- ↑ 5.0 5.1 5.2 Mustoe T (2004). "Understanding chronic wounds: a unifying hypothesis on their pathogenesis and implications for therapy". Am. J. Surg. 187 (5A): 65S–70S. doi:10.1016/S0002-9610(03)00306-4. PMID 15147994.
- ↑ 6.0 6.1 6.2 Moreo K (2005). "Understanding and overcoming the challenges of effective case management for patients with chronic wounds". The Case manager. 16 (2): 62–3, 67. doi:10.1016/j.casemgr.2005.01.014. PMID 15818347.
- ↑ 7.0 7.1 7.2 7.3 Stanley AC, Lounsbury KM, Corrow K; et al. (2005). "Pressure elevation slows the fibroblast response to wound healing". J. Vasc. Surg. 42 (3): 546–51. doi:10.1016/j.jvs.2005.04.047. PMID 16171604.
- ↑ 8.0 8.1 "eMedicine - Reperfusion Injury in Stroke : Article by Wayne M Clark, MD". Retrieved 2007-08-05.
- ↑ Eklöf B, Rutherford RB, Bergan JJ; et al. (2004). "Revision of the CEAP classification for chronic venous disorders: consensus statement". J. Vasc. Surg. 40 (6): 1248–52. doi:10.1016/j.jvs.2004.09.027. PMID 15622385.
- ↑ NICE (July 23, 2013). "Varicose veins in the legs: The diagnosis and management of varicose veins. 1.2 Referral to a vascular service". National Institute for Health and Care Excellence. Retrieved August 25, 2014.
- ↑ "BMJ responses". Retrieved 3 May 2013.
- ↑ Taylor JE, Laity PR, Hicks J; et al. (2005). "Extent of iron pick-up in deforoxamine-coupled polyurethane materials for therapy of chronic wounds". Biomaterials. 26 (30): 6024–33. doi:10.1016/j.biomaterials.2005.03.015. PMID 15885771.
- ↑ 13.0 13.1 Nelson EA, Cullum N, Jones J (2006). "Venous leg ulcers". Clin Evid (15): 2607–26. PMID 16973096.
- ↑ Nelson EA, Harper DR, Prescott RJ, Gibson B, Brown D, Ruckley CV (2006). "Prevention of recurrence of venous ulceration: randomized controlled trial of class 2 and class 3 elastic compression". J. Vasc. Surg. 44 (4): 803–8. doi:10.1016/j.jvs.2006.05.051. PMID 17012004.
- ↑ Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA (2006). Palfreyman, Simon SJ, ed. "Dressings for healing venous leg ulcers". Cochrane database of systematic reviews (Online). 3: CD001103. doi:10.1002/14651858.CD001103.pub2. PMID 16855958.
- ↑ Palfreyman S, Nelson EA, Michaels JA (2007). "Dressings for venous leg ulcers: systematic review and meta-analysis". BMJ. 335 (7613): 244. doi:10.1136/bmj.39248.634977.AE. PMC 1939774. PMID 17631512.
- ↑ Reyzelman, Alexander; Bazarov, Irina (Dec 2012). "Initial clinical assessment of a novel multifunctional topical ointment for difficult-to-heal wounds: a case series". Advances in Skin and Wound Care. 25 (12): 557–560. doi:10.1097/01.ASW.0000423441.00908.05. PMID 23151766.
- ↑ Nelson EA, Hillman A, Thomas K (2014). "Intermittent pneumatic compression for treating venous leg ulcers". Cochrane Database Syst Rev. 5: CD001899. doi:10.1002/14651858.CD001899.pub4. PMID 24820100.
- ↑ Jull A, Arroll B, Parag V, Waters J (2007). Jull, Andrew B, ed. "Pentoxifylline for treating venous leg ulcers". Cochrane database of systematic reviews (Online) (3): CD001733. doi:10.1002/14651858.CD001733.pub2. PMID 17636683.
- ↑ Mustoe T (March 17–18, 2005). Dermal ulcer healing: Advances in understanding. Tissue repair and ulcer/wound healing: molecular mechanisms, therapeutic targets and future directions. Paris, France.
- ↑ Gohel MS, Barwell JR, Taylor M; et al. (July 2007). "Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial". BMJ. 335 (7610): 83. doi:10.1136/bmj.39216.542442.BE. PMC 1914523. PMID 17545185.
- ↑ 22.0 22.1 Thomas CA, Holdstock JM, Harrison CC, Price BA, Whiteley MS (April 2013). "Healing rates following venous surgery for chronic venous leg ulcers in an independent specialist vein unit". Phlebology. 28 (3): 132–9. doi:10.1258/phleb.2012.011097. PMID 22833505.
- ↑ Bush RG (September 2010). "New technique to heal venous ulcers: terminal interruption of the reflux source (TIRS)". Perspectives in Vascular Surgery and Endovascular Therapy. 22 (3): 194–9. doi:10.1177/1531003510387637. PMID 21098501.
- ↑ Roxburgh's Common Skin Diseases (17th ed.). p. 127. ISBN 978-0-340-76232-5.
- ↑ http://www1.imperial.ac.uk/biosurgerysurgicaltechnology/clinical_trials_outcomes/vasculardisease/clinicaltrials/evra/[full citation needed]
- ↑ Pippa Tollow (April 2014). "Impact of Leg Ulcers on Relatives and Carers of Affected Patients - A PhD Study funded by The Leg Ulcer Charity". The Leg Ulcer Charity. Retrieved August 25, 2014.