Venous Stasis Ulcer Formation and Management

Venous stasis ulcers are shallow wounds that generally affect the lower extremities. Typically, stasis ulcers are a symptom of a larger condition known as chronic venous insufficiency (CVI), which is associated with prolonged venous hypertension and leg swelling (edema). Over time, chronic pressure weakens the lining inside of a vein’s walls. This causes increased permeability, which allows for fluid to collect in dependent extremities, like the feet and legs. The most common modifiable risk factors for CVI include smoking, hypertension, obesity, and diabetes. Venous stasis dermatitis, discoloration, and inflammation of the skin can be a beginning sign that edema is irritating the integumentary system, and that the skin is likely to ulcerate. Therapy primarily focuses on prevention because ulcers are, at times, difficult to treat. Though, there are medications that can improve blood circulation and wound healing. For more severe ulcers, surgical wound debridement is an option lying on the proverbial table.

If you have the following signs and symptoms, please contact your health care provider:

  • Varicose veins
  • Leg edema
  • Skin lesions
  • Warm skin
  • Skin is tender to touch
  • Reddish-brown spots on the skin
  • Itchy, dry, and flaky skin

Factors in Venous Stasis Ulcer Development

Venous stasis ulcers can develop when you venous return flow is abnormal. Chronic venous insufficiency, DVT and varicose veins are all factors in the development of venous ulcers.

Venous Stasis Ulcers: Physiology Concepts

Inflammation and swelling of the legs can form as a result of prolonged venous hypertension, which, over time, damages the structure and function of the venous and lymphatic systems.

The Veins

Veins are blood vessels that are responsible for steering blood toward the heart. Unlike arteries, which rely on high pressure to direct blood flow, veins are a low-pressure system. Thus, the venous system requires assistance from skeletal muscle and one-way valves to help push blood forward to the heart.

Skeletal Muscle Promotes Venous Return

Skeletal muscle helps to promote venous return by acting as a ‘pump.’ During normal cycles of muscular contraction and relaxation, the veins are compressed. This muscle pump system propels venous blood back toward the heart. People with muscle weakness, joint pain, or neuromuscular disease may have underdeveloped or more fragile calf muscles, and as a result, poor circulation and leg pain.

One-Way Valves Promote Venous Return

The valves in veins are functionally designed to only direct blood flow in one direction—toward the heart. When a valve or a part of the valve becomes functionally impaired, reflux of blood back toward the feet and legs can occur and cause lower extremity edema. Although veins are blood reservoirs and are able to accommodate an influx of fluid, there is a limit to the amount of volume that a vein can hold. Eventually, the inside lining of the vessel wall breaks down, allowing for fluids and small molecules to flow in and out of the vein.

The Lymphatic System

The lymphatic system is responsible for draining such fluid, but over time, this system also becomes overwhelmed and decompensates. Fluid continues to accumulate and, if severe enough, can cause swelling and inflammation of the peripheral extremities.

The Integumentary System

The integumentary system begins to break down as watery yellow liquid seeps out, irritating and causing color and texture changes to the skin. This is the development of venous stasis dermatitis, and as the skin continues to breakdown, an ulcer can form.

Medications are Associated with Venous Stasis Dermatitis

Above is a quick summary of how venous stasis ulcers form, and in general, most people who develop venous stasis ulcers also carry the diagnosis CVI. However, there are some medications that are associated with venous stasis dermatitis, and when severe enough or left untreated, stasis dermatitis can evolve into stasis ulcers. Whatever the initiating cause, the core physiological concepts remain the same. Rather than a sequela of health illnesses leading to a chronic medical condition with overarching symptoms, it’s a medication causing an unwanted physical reaction (adverse effect), specifically leg edema that starts the process.

Some medications associated with venous stasis dermatitis:

  • Antibiotics
  • Antidepressants
  • Antihypertensives
  • Chemotherapeutics
  • Hormones

How to Assess for Venous Stasis Ulcers

Your health care provider will perform a physical exam and measure the width and depth of the ulcer(s). Further, if there is any visible fluid or pus, most likely your provider will use a long plastic applicator with a cotton-tipped end to collect and send a sample to test for the presence of bacteria. Infections are common because poor blood circulation slows wound healing, and the location of the ulcers (lower legs, calves, and ankles) increases the exposure to bacteria.

Current Therapies for Venous Stasis Ulcers

Management and treatment of venous stasis ulcers primarily focuses on preventing their formation, as poor blood flow and location can make them difficult to treat. Compression stockings help blood circulation by facilitating the forward flow of blood to the heart. Because stockings assist with venous circulation and lymphatic drainage, they can help ulcers to heal as well. Compression stockings also have the added bonus of preventing new stasis ulcers from forming! For those who cannot tolerate the pressure gradient from compression stockings, talk with your health care provider. Your physician may recommend medications instead. For severe ulceration, wound debridement is generally recommended to remove dead tissue and enhance healing.

Medications that are sometimes used to treat venous stasis ulcers:

  • Pentoxifylline—An effective medication to help blood circulation and wound healing.
  • Nifedipine (Procardia)—A common calcium channel blocker (CCB) that is effective in reducing high pressures and wall stiffness.
  • Diltiazem (Cardizem)—Another common CCB that is also useful when treating high venous pressures and vessel wall stiffness.

Low-Intensity Ultrasound Patch May Heal Venous Ulcers

In 2013, researchers studied a new method for treating venous stasis ulcers using an ultrasound patch that participants wore like a band-aid. Reports have shown the therapeutic benefits of employing ultrasound for wound healing, but previous studies used higher frequencies between 1 to 3 megahertz. Researchers from the School of Biomedical Engineering at Drexel hypothesized that decreasing the frequency between 20 to 100 kilohertz may produce more clinically meaningful changes, and that’s exactly what the study demonstrated. In order to determine the most effective ultrasound frequency and treatment duration, participants were placed into 3 treatment groups and a placebo group. Each group received different levels of frequency for different durations. The greatest improvement in wound healing was achieved in the group receiving 20 kilohertz for 15 minutes. This technology not only benefits those with venous stasis ulcers, but also people with diabetes and pressure ulcers.

Wound Healing is the Goal

Whether your health care provider recommends conservative management with compression stockings, medication, ultrasound therapy, or wound debridement, the overall goals are always to improve venous circulation and lymphatic drainage as well as to enhance wound healing.

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