Lower Extremity Ulcers

Lower extremity ulcers are open sores or wounds that develop on the legs or feet and are often slow to heal. These ulcers can be caused by a variety of conditions, including poor circulation, infections, and certain chronic diseases. They can be painful, and if left untreated, they can lead to further complications, such as infections or permanent tissue damage.

🔹 Types of Lower Extremity Ulcers

There are several types of ulcers that can develop in the lower extremities, with different causes and treatment approaches:

1. Venous Ulcers

• Cause: Venous ulcers are the most common type of lower extremity ulcers and are caused by poor blood flow in the veins, usually due to chronic venous insufficiency (CVI).
• Location: They typically occur on the inner aspect of the lower leg, above the ankle.
• Symptoms:
• Shallow, irregularly shaped wounds
• Red or brownish discoloration of the skin around the ulcer (due to blood pooling)
• Swelling in the legs or feet
• Pain that worsens when standing for long periods
• Treatment:
• Compression therapy: The primary treatment to improve blood flow and reduce swelling.
• Wound care: Regular cleaning and dressing changes.
• Elevating the legs to help improve circulation.
• Medications: Topical antibiotics may be used if an infection is present.
• Endovenous treatments [Foam, endovenous laser ablation, endovenous radiofrequency ablation, glue therapy]. Please see the section varicose veins and chronic venous insufficiency.
• Venograms. In selected patients, we can consider venograms to look for central venous obstruction or compression syndromes. If appropriate, these deep iliac veins in the abdomen can be stented with intravascular ultrasound guidance.

2. Arterial Ulcers

• Cause: These ulcers occur due to poor circulation caused by peripheral artery disease (PAD) or other arterial conditions, which limit the blood flow to the tissues. Please see the section Peripheral Arterial Disease and Chronic Limb Threatening Ischemia.
• Location: Typically found on the toes, heels, or outer ankle.
• Symptoms:
• Pain, especially when the leg is elevated or at rest
• Ulcers are usually small, round, and have a pale base with well-defined borders
• Skin around the ulcer may appear shiny, thin, or hairless
• Coolness or pallor of the skin
• Treatment:
• Revascularization: Endovascular intervention or surgery to restore blood flow to the affected area, such as angioplasty, atherectomy, stenting or bypass.
• Wound care: Proper cleaning and dressing of the ulcer.
• Medications: Antiplatelet drugs or anticoagulants may be prescribed to improve blood flow.

3. Diabetic Ulcers

• Cause: Diabetic ulcers develop in individuals with diabetes due to nerve damage (neuropathy), poor circulation, and high blood glucose levels. These ulcers are common on the feet.
• Location: Most often on the plantar (bottom) surface of the foot or on the toes.
• Symptoms:
• Painless ulcers (due to nerve damage)
• Infection is common, leading to redness, warmth, or pus around the ulcer
• Thickened skin or calluses around the ulcer
• Treatment:
• Blood sugar control: Maintaining good control over blood glucose levels is essential.
• Wound care: Proper cleaning, debridement (removal of dead tissue), and infection management.
• Foot care: Regular monitoring of the feet to prevent injuries, proper footwear, and moisturizing to prevent dry skin.
• Off-loading: Pressure relief using special footwear or braces.
• Revascularization: Opening up the lower extremity arterial blockages.

4. Pressure Ulcers (Bedsores)

• Cause: These ulcers develop due to prolonged pressure on certain areas of the body, often in individuals who are immobile (e.g., bedridden or in a wheelchair).
• Location: Commonly found on bony prominences, such as the heels, ankles, or hips.
• Symptoms:
• Red or purple skin that does not blanch (turn white) when pressed
• Open wounds with varying levels of tissue damage
• Painful and often accompanied by swelling
• Treatment:
• Relieving pressure: Using pressure-relieving devices like specialized cushions, mattresses, or pads.
• Wound care: Cleaning the wound and using appropriate dressings to promote healing.
• Infection prevention: If infection is present, antibiotics may be necessary.
• Nutrition: Ensuring adequate protein and vitamin intake to support wound healing.
• Revascularization: Ensuring adequate blood flow in selected cases to help with wound healing by endovascular or surgical means.

5. Traumatic Ulcers

• Cause: These ulcers occur due to injury or trauma, such as burns, cuts, or abrasions.
• Location: They can occur anywhere on the lower leg or foot.
• Symptoms:
• Open wound with irregular edges
• Pain and swelling around the wound
• Inflammation and possible infection if not properly cared for
• Treatment:
• Wound cleaning and application of appropriate dressings.
• Antibiotic therapy if infection is present.
• Pain management: Analgesics and proper wound care techniques to reduce discomfort.

🔸 Risk Factors for Lower Extremity Ulcers

Several factors increase the risk of developing ulcers in the lower extremities:

• Chronic venous insufficiency (CVI): Poor circulation due to weakened vein walls and valves.
• Peripheral artery disease (PAD): Reduced blood flow to the legs and feet.
• Diabetes: Nerve damage and poor circulation leading to ulcers, especially in the feet.
• Obesity: Excess weight can increase pressure on the legs and feet.
• Age: Older adults are more likely to develop ulcers due to reduced circulation and skin thinning.
• Immobility: Prolonged bed rest or sitting, especially in people who are bedridden or wheelchair-bound.
• Infections: Untreated infections in the skin or deeper tissues can lead to ulcer formation.
• Poor hygiene or improper footwear: Can increase the risk of trauma or irritation to the skin, leading to ulcer formation.

🔹 Diagnosis of Lower Extremity Ulcers

To determine the cause of a lower extremity ulcer and appropriate treatment, doctors may conduct the following:

1. Physical Examination: The doctor will examine the ulcer and surrounding tissue to assess the severity and location.
2. Doppler Ultrasound: This test can assess blood flow in the arteries and veins to identify if circulation issues are contributing to the ulcer.
3. Blood Tests: To check for signs of infection or diabetes.
4. X-ray or MRI: In some cases, imaging may be done to rule out deeper infections or bone involvement.

🔸 Treatment of Lower Extremity Ulcers

Treatment will vary depending on the cause and severity of the ulcer, but it typically includes the following:

1. Wound Care

• Cleaning: The ulcer should be cleaned with saline or an appropriate cleanser to remove debris and reduce the risk of infection.
• Debridement: Removing dead or infected tissue from the wound.
• Dressings: Special dressings (e.g., hydrocolloid, foam, or antimicrobial dressings) are used to promote healing and protect the wound.

2. Compression Therapy (For Venous Ulcers)

• Compression stockings or bandages help improve blood flow in the veins and reduce swelling in the lower legs.

3. Antibiotics

• Topical or oral antibiotics may be used if there is an infection in or around the ulcer.

4. Pain Management

• Analgesics may be prescribed to relieve pain associated with the ulcer.

5. Revascularization

• In selected cases, we can consider opening up the arterial blockages by endovascular or open surgical means to improve blood flow to the ulcer; hence, help in its healing.

6. Endovenous treatments

• Foam, endovenous laser ablation, endovenous radiofrequency ablation, glue therapy. Please see the section varicose veins and chronic venous insufficiency.

7. Venograms.  

• In selected patients, we can consider venograms to look for central venous obstruction or compression syndromes. If appropriate, these deep iliac veins in the abdomen can be stented with intravascular ultrasound guidance.

8. Surgical Intervention

• In some cases, skin grafting or surgical debridement may be necessary to promote healing or remove infected tissue.

9. Management of Underlying Conditions

• Diabetes control: Tight blood sugar control is crucial for healing diabetic ulcers.
• Improving circulation: For arterial ulcers, surgical procedures like angioplasty or bypass surgery may be needed to restore blood flow.
• Lifestyle modifications: Quitting smoking, maintaining a healthy weight, and managing conditions like diabetes and hypertension can support wound healing.

🔸 Prevention of Lower Extremity Ulcers

Preventing lower extremity ulcers involves managing risk factors and taking proactive steps:

• Proper Foot Care: For those with diabetes, regular foot inspection and proper footwear can help prevent injuries that lead to ulcers.
• Exercise: Maintaining good circulation through regular physical activity can reduce the risk of ulcers caused by venous or arterial disease.
• Manage chronic conditions: Properly managing diabetes, hypertension, and cholesterol levels can prevent complications that lead to ulcers.
• Compression therapy: For individuals with venous insufficiency, using compression stockings can reduce swelling and prevent ulcers.
• Avoid prolonged immobility: If you're immobile, repositioning regularly or using pressure-relieving devices can reduce the risk of pressure ulcers.

🔹 Prognosis

With proper treatment, many lower extremity ulcers can heal successfully, but healing may take time, especially in individuals with underlying conditions like diabetes or vascular disease. It's important to follow the treatment plan and manage any chronic conditions to ensure the best chance for healing and preventing recurrence. Arterial ulcers due to chronic limb threatening ischemia has the worse prognosis. CLTI affects limb viability and patient survival in a very adverse manner. This condition has to be treated very promptly and aggressively.