Ulcers & Non-healing Wounds

ABOUT

  • A leg ulcer is any wound or defect in the skin of the lower limb.

    These can occur from minor trauma, and is only considered a problem when the wound does not heal, or becomes infected.

  • Lower limb ulcers impact 2% of the population.

  • Risk factors for lower limb ulcers include:

    • Smoking

    • Diabetes

    • Hypertension (high blood pressure)

    • Hypercholesterolemia (high cholesterol)

    • Age

    • Being male

    • Kidney disease

    • Varicose veins

    • DVTs

  • Foot ulcers often occur due to peripheral arterial disease, diabetes or venous insufficency.

    • Peripheral arterial disease - due to atherosclerosis (plaque) narrowing the arteries and reducing the blood supply to the legs, wounds either take longer to heal, or can form without any trauma.

    • Diabetes - due to a combination of damage to nerves, arteries, and the reduced action of the immune system in people with diabetes, these people are much more likely to get ulcers, and are much less likely to heal well.

    • Venous insufficiency - people with varicose veins or venous insufficiency have excess fluid in their lower legs, causing swelling, and predisposing to wound formation.

  • Ulcers and non healing wounds may start off as small cracks in the skin, and then develop over time.

    They may result in gangrene, seen as black discolouration of the skin, often beginning in the toes.

    Sometimes wounds caused by peripheral arterial disease cause significant pain.

    In contrast, wounds caused by diabetes can often have no pain, as the nerves have been damaged by diabetes.

    These wounds can become infected, which can cause redness around the wound, fluid to come out of the wound, or cause you to feel unwell with fevers.

  • Assessment begins with a thorough discussion about your medical history, followed by clinical examination. This will often determine whether the ulcers are due to a problem with the arteries, veins or nerves.

    An ultrasound called an arterial duplex, often follows, which is excellent for imaging arteries in the leg and determining the source of the probem.

    An ultrasound called a venous incompetence duplex may be necessary, to make sure the veins are working as they should be.

    If infection is suspected, you may need blood tests, or other imaging such as an x-ray or MRI.

TREATMENT

How do you treat ulcers and non-healing wounds?

First, antibiotics will be needed for any infection, and dressings to keep the wound clean.

Depending on the cause of the wounds, various treatments may be needed:

Ulcers due to peripheral arterial disease require an improvement in the blood supply, and the options for this are:

  • Endovascular surgery – also called ‘keyhole surgery’, this involves a small incision in the groin or wrist, and after a wire is passed across the narrowing or blockage, a balloon is inflated to open up the narrowing, and the balloon is then removed. Sometimes a stent (a tubular metal frame) is used to keep the artery open.

  • Open surgery – before endovascular surgery, open surgery was the traditional way to manage arterial narrowings or blockages. This involves larger incisions, but allows either complete removal of a blockage, or allows implantation of a new vessel to bypass (go around) the blockage.

Ulcers due to varicose veins require the veins to be treated with:

  • Compression stockings – custom-made, firm stockings which cover from the toes to the knee, compresses the veins and removes extra fluid from the leg.

  • Stripping – this surgery involves tying off and often ‘stripping’ the non-functioning vein, which is removing the entire vein that is not working, via several incisions.

  • Endovenous methods – these include endovenous laser therapy or radiofrequency ablation, via keyhole methods. Endovenous laser therapy has been shown to be more effective than stripping or radiofrequency ablation.

  • Sclerotherapy – used mostly for spider veins, involves injecting a medication designed to cause these small veins to block off.

Ulcers due to diabetes or nerve problems will often heal if pressure is taken off it, so a special “offloading” shoe will be necessary. We will also need to exclude problems with arteries or veins.

We will discuss which treatment option may be most suitable for you given the cause of the wounds, with consideration of your preferences and factors such as:

  • The severity of your symptoms

  • Whether arteries, veins or nerves are affected

  • Your personal medical history

Do I need to follow-up with my Vascular Surgeon?

If you have had an operation, Dr Shiraev will want to see you after to make sure you have recovered well, your wounds are healing, and answer any questions you may have.

Unfortunately it is common for ulcers to return due to the nature of the damage to the arteries or nerves. As such, people with a history of ulcers will benefit from monitoring, either by a vascular surgeon or a podiatrist.

This advice is general, and is not intended to replace a formal clinical assessment and discussion with a health professional.