What is a leg ulcer (ulcus cruris)?
A leg ulcer (ulcus cruris) is defined as a wound on the lower leg that fails to heal within two weeks. These wounds can be painful, itchy and weep. The specialist term “ulcus cruris” is derived from the Latin word ulcus (= ulcer) and cruris (= lower leg). There are various possible causes for leg ulcers. About 1 percent of the western population is affected by an acute venous leg ulcer.1
Causes: How does a leg ulcer develop?
An ulcus cruris can be caused by various conditions. The most common underlying condition contributing to leg ulceration is venous disease which accounts for 60-80 percent of all leg ulcers.2 Correct diagnosis and identification of the cause is essential to ensure the patient receives the correct treatment. Doctors classify the different forms of ulcer according to the kind of circulatory disorder:
- Venous leg ulcer (Ulcus cruris venosum): most severe form of chronic venous insufficiency (C6 according to CEAP, see below)
- Arterial leg ulcer (Ulcus cruris arteriosum): caused by arteriosclerosis / arterial calcification (PAD: peripheral arterial disease)
- Mixed leg ulcer (Ulcus cruris mixtum) with venous and arterial causes
- Other ulcers (ulcera cruris) as a result of other causes
Most common form: Ulcus cruris venosum (Venous leg ulcer)
60-80 percent of all lower leg ulcers are regarded as venous-related.2 Only around 10-30 percent are caused by arterial circulatory problems.3 10 – 20 percent suffer from a mixed ulcer caused by venous and arterial disease.3
The most common form of leg ulcer is the ulcus cruris venosum, resulting from severe chronic venous insufficiency. Over time the patient develops insufficiencies in their veins which at its most server can result in skin break down and ulceration.
Diagram of a healthy (l.) vein and an abnormal (r.) vein.
Signs and symptoms of venous disease (ulcus cruris venosum)
In the early stages the patient may develop early symptoms of venous disease which slowly worsen over time as the disease progresses. The severity of chronic venous diseases con be classified according to CEAP:
- C = Clinic (clinical findings)
- E = Etiology (causes / trigger of the disorder)
- A = Anatomy (anatomical localisation)
- P = Pathophysiology (pathological dysfunction)
CEAP stages
| Stage | Changes |
|---|---|
| C 0 | No visible signs of venous disease |
| C 1 | Telangiectasias (spider veins) |
| C 2 | Varicosis (= varicose vein disorder) without clinical indication of a chronic venous insufficiency (= permanent vein weakness) |
| C 3 | Varicosis (= varicose vein disorder) with oedema (swelling) |
| C 4 | Varicosis (= varicose vein disorder) with trophic skin changes, subdivided into: |
| C 4a | Pigmentation (= skin changes) or eczema (= dermatitis, inflammatory skin reaction) |
| C 4b | Lipodermatosclerosis (= hardening of the subcutaneous fatty tissue) or atrophie blanche |
| C 5 | Varicosis (= varicose vein disorder) with healed ulcus cruris venosum (= leg ulcer, venous-related lower leg ulcer) |
| C 6 | Varicosis (= varicose vein disorder) with florid ulcus cruris venosum (= leg ulcer, venous-related lower leg ulcer) |
Besides the physical skin changes that occur when a patient develops chronic venous insufficiency they can also experience other symptoms such as the legs feeling heavy, tired and itchy. As the disease progresses, enlarged surface veins protrude. Doctors refer to this as a varicose vein disorder or sometimes as varicosis. The venous blood is no longer being transported to the heart properly resulting in an increased pressure within the veins commonly referred to as venous hypertension. The increased volume of blood from the incompetent veins can lead to oedema, i.e. visible and palpable collections of fluid, forming in the tissue.
Skin changes as an early sign of venous disease (ulcus cruris venosum)
Pigmentation is an indication of advanced venous disease, the skin changes colour to a rust/brown this is the result of red blood cells leaking into the tissues. Other common skin changes are white atrophic scarring and hardening of the subcutaneous tissue (lipodermatosclerosis).
At this stage, a pronounced vein weakness (medical term: chronic-venous insufficiency) can develop.
As a result of impaired venous return, the venous blood flows back into the capillaries: The smallest blood vessels that provide the cells with oxygen and nutrients are also responsible for the return transportation of metabolic by-products. The capillaries of patients who suffer from chronic venous insufficiency cannot do this sufficiently anymore.
The smallest injuries can lead to a wound that does not heal
A minor injury, such as a mosquito bite or a small cut in the surface of the skin while gardening, can lead to a venous leg ulcer.
As a result of their wound patients may exercise less. This means that the calf muscle pump, which supports the vein system in transporting the blood in the direction of the heart, is switched off further reducing the venous return from already insufficient veins. Bacterial infections in and around the wound can further delay healing and cause unpleasant odours. A combination of pain, reduced mobility, odour and wound exudate can lead to patients becoming socially isolated.
Pictures leg ulcer
Risk factors for leg ulcers
The incidence of venous leg ulceration increases with age: From the age of 80, the frequency increases to around two percent.1 Older people sit a lot, meaning that the calf muscle pump is not used often and blood collects in the legs. Women are often more affected than men.1 Diabetes and smoking also increase the likelihood of developing leg ulcers.
Genetic predisposition: Venous diseases are hereditary to some extent. It is likely that further members of your family may experience similar symptoms. Therefore, always pay attention to the symptoms.
Preventing venous ulceration: Tips and options
A venous disorder that begins with heavy tired legs can also lead to a leg ulcer if left untreated. The best prevention is therefore to take the signs of vein changes in the legs very seriously and consult a doctor at an early stage so that the correct treatment can be started. Venous disorders often do not cause a great deal of pain for patients for many years. That’s why many patients ignore the first clear signs, such as the so-called “warning veins” in the ankle and later also the skin pigmentation changes. So, many patients first go to the doctor when they already have a leg ulcer.
Treating leg ulcers: Therapy for venous leg ulcers (ulcus cruris venosum)
When treating venous leg ulcers, it is important to treat the underlying disease, i.e. the chronic venous insufficiency. The aim of the treatment is to improve the impaired return blood flow. The doctor decides which therapeutic measures are suitable for the patient in question. Possible measures include wound cleansing, wound treatment with medicines and dressings, compression therapy with medical compression stockings or adjustable, compression systems, as well as vein operations.
The medi therapy concept for the treatment of venous leg ulcer is based on international guidelines 1,2,4 as well as “medical compression therapy”5 Furthermore the products allow for patient-individual treatment at each phase of the therapy.
Healing time: There are many factors that determine the healing process
If the treatment is based on therapy guidelines, the healing prospects for leg ulcers are good. The duration of the healing depends on various factors alongside the treatment that complies with the guidelines, such as the age of the patient, possible comorbidities and the location and size of the wound.
However: Even though venous leg ulcer guidelines recommend compression therapy, more than 80 percent of those with a venous leg ulcer do not receive compression therapy during the acute wound phase.3
After the ulcer has healed, the doctor should carry out regular check-ups and measures should be taken to ensure that the leg ulcer does not return. This includes therapy with medical compression stockings.
Which doctors treat leg ulcers?
Every patient with a leg ulcer should immediately seek medical treatment. Your first point of contact should be your general practitioner (GP). He/she will be able to tell you where to find the specialists for treating leg ulcers who will support you throughout your therapy:
- Specialist doctors, such as phlebologists (vein specialists), angiologists (vascular doctors), dermatologists (skin specialists), diabetologists (doctors who specialise in treating diabetes), are the right adress for patients to contact if they have a leg ulcer. They work as doctors in privat practices, hospitals and specialised clinics.
- Certified wound advisers or wound managers are certified caregivers with additional expertise. They cooperate closely together with doctors and outpatient care services. However, the doctor always has therapeutic autonomy. Therefore, a wound consultant may only be involved with his consent.
- Outpatient healthcare services are often an extension to GP services when caring for patients with chronic wounds. Some GPs have specially trained team members.
- Regional wound centres or outpatient clinics in hospitals employ expert teams to treat patients suffering from chronic wounds with dedication and experience. Doctors, hospitals, nursing services and home care companies have set up interdisciplinary services for patients with chronic wounds.
Products by medi for the treatment of leg ulcers
Effective products, adapted to the individual phases of the therapy:
- Decongestion of phleboedema : circaid juxtacures
- Treatment for the underlying disease: mediven ulcer kit and circaid juxtalite
- Prevention of recurrence: mediven forte und mediven mondi
Phase 1 – Decongestion of phlebeoedema
In most cases a phleboedema is occuring additionally. In this case the therapy starts with the decongestion of an accompanying phleboedema or phlebo-lymphoedema.
- circaid juxtacures can be easily adjusted and applied - individually fitted to the patient's measurements, the device can be easily applied and removed using interlacing band
- Controllable compression pressure thanks to the integrated Built-In-Pressure System - the required compression pressure can be verifiably set and re-adjusted at any time.
- As soon as the circumference of the leg is reduced by decongestion of the oedema, circaid juxtacures can be adapted to the new circumferences.
Phase 2 – Therapy for the underlying disease
In the second phase of the therapy, medi offers an advantageous alternative for the therapy of venous leg ulcer:
- Once the oedema has been completely decongested, the ulcer stocking system mediven ulcer kit can be used. The two-component system consists of an easy to don understocking providing optimised hygiene and effective compression as well as a visually discreet, circular knitted outer compression stocking for additional compression during the mobile phase.
- With circaid juxtalite medi also offers an alternative for those patients who have challenges with ulcer compression stockings (e.g. donning and doffing).
Phase 3 – Prevention of recurrence
To prevent recurrence of the leg ulcer
In venous leg ulcers, the underlying disease, chronic venous insufficiency, persists even after the wound has been closed. In order to maintain long-term treatment success, compression therapy should be continued after wound healing with medical compression stockings.
For the time after wound healing, patients can choose from a wide range of medical compression stockings in a variety of colours and variations. Flat-knit compression stockings (e.g. mediven mondi) are the ideal choice for patients with an additional disorder of the lymphatic system and consequently a tendency to lymphoedema.
If there is a venous swelling tendency, a so-called phleboedema tendency, round knitted compression stockings (e.g. mediven plus) are used. This allows each patient to be treated individually in order to maintain the long-term success of the therapy.
For patients who have challenges with medical compression stockings (e.g. donning and doffing) adjustable compression devices (e.g. circaid juxtalite) are an alternative to continue compression therapy.
The human body
Highlights
Diagnosis & treatment
Sources and remarks:
1 Harding K et al. Simplifying venous leg ulcer management. Consensus recommendations. Wounds International 2015.
2 Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic venous leg ulcers: a national clinical guideline. Edinburgh: NHS Quality Improvement Scotland; 2010. Available at www.sign.ac.uk/pdf/sign120.pdf (Last access 6 April 2020).
3 Sauer K et al. Barmer GEK Heil- und Hilfsmittelreport 2014. Available at www.barmer.de/presse/infothek/studien-und-reports/heil-und-hilfsmittelreport/report-2014-38588 (last access 6 April 2020).
4 O’Donnell T F et al. Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. JVS, 2014;60(2):3S - 59S.
5 Rabe E et al. S2k-Leitlinie: Medizinische Kompressionstherapie der Extremitäten mit Medizinischem Kompressionsstrumpf (MKS), Phlebologischem Kompressionsverband (PKV) und Medizinischen adaptiven Kompressionssystemen (MAK). Available at: https://www.awmf.org/leitlinien/detail/ll/037-005.html (Last access 6 April 2020).
