Leg ulcer (ulcus cruris)

When wounds don’t heal

medical consultation leg ulcer

What is a leg ulcer (ulcus cruris)?

A leg ulcer (ulcus cruris) is defined as a wound on the lower leg that heals badly or does not heal at all. These wounds often 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. In 2012, 210,000 people in Germany suffered from a severe, active leg ulcer.1

Causes: How does a leg ulcer develop?

An ulcus cruris can be caused by various conditions. It is nearly always circulatory disorders, such as diabetes mellitus and smoking, that are connected to the development of leg ulcers. Correct diagnosis and identification of the cause are important factors for further treatment. Doctors classify the different forms of ulcer according to the kind of circulatory disorder:

  • Ulcus cruris venosum: most severe form of chronic venous insufficiency (C6 according to CEAP, see below)
  • Ulcus cruris arteriosum: caused by arteriosclerosis / arterial calcification (paod: peripheral arterial occlusive disease)
  • Ulcus cruris mixtum with venous and arterial causes
  • Other ulcera cruris as a result of other causes

Most common form: Ulcus cruris venosum (leg ulcer as a result of venous disease) 

50-70 percent of all lower leg ulcers are regarded as venous-related. Only around 10-30 percent are caused by arterial circulatory problems.1,2

The most common form of leg ulcer is the ulcus cruris venosum, the most severe form of chronic venous insufficiency chronic venous insufficiency. What begins as heavy, tired legs can lead to ulcus cruris if left untreated.

Ulcus cruris venosum: Symptoms and signs

In the early stages of a venous disorder, brown discolorations of the skin is visible on the lower leg. At a later stage, the skin becomes thinner and wounds heal poorly. The severity of chronic venous diseases are 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 0No visible signs of venous disease
C 1     Telangiectasias (spider veins)
C 2Varicosis (= varicose vein disorder) without clinical indication of a chronic venous insufficiency (= permanent vein weakness)
C 3Varicosis (= varicose vein disorder) with oedema (swelling)
C 4Varicosis (= varicose vein disorder) with trophic skin changes, subdivided into:
C 4aPigmentation (= skin changes) or eczema (= dermatitis, inflammatory skin reaction)
C 4bLipodermatosclerosis (= hardening of the subcutaneous fatty tissue) or atrophie blanche
C 5Varicosis (= varicose vein disorder) with healed ulcus cruris venosum (= leg ulcer, venous-related lower leg ulcer)
C 6Varicosis (= varicose vein disorder) with florid ulcus cruris venosum (= leg ulcer, venous-related lower leg ulcer)

Chronic venous disease becomes noticeable as a result of heavy, tired and itchy legs as well as swelling in the foot and lower leg. As the disease progresses, enlarged surface veins protrude like nodules, are tortuous and visible under the skin. 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. This can lead to oedema, i.e. visible and palpable collections of fluid, forming in the tissue.

Skin changes as an early sign of ulcus cruris venos

A further visible indication of advanced venous disease is typical skin changes. The skin becomes takes on significant pigmentation in the form of brown flecks. White, atrophic scarring and hardening of the subcutaneous tissue can also develop.

At this stage, a pronounced vein weakness (medical term: chronic-venous insufficiency) can develop.

As a result of impaired return transportation, 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 any more.

The smallest injuries become a wound that does not heal well or does not heal at all

The skin loses elasticity and resilience. It becomes thin. A minor injury, such as a mosquito bite or a small cut in the surface of the skin while gardening, can become wounds that do not heal well and very painful wounds in these patients.

Patients often exercise less as a result of the pain. This means that the pump mechanism of the muscles, which supports the vein system in transporting the blood in the direction of the heart, is switched off. This creates a vicious circle. Bacterial infections in and around the wound cause unpleasant odours. Those suffering from this problem therefore tend to isolate themselves from others.

Risk factors for leg ulcers

The ulcus cruris venosum occurs more often with increased age: From the age of 80, the frequency increases to around one to over three percent.3 Older people sit a lot, meaning that the calf muscle pump is not used often and blood collects in the legs. 70 percent of those affected are women.2 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 ulcus cruris venosum: 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. That’s why many patients first go to the doctor when they already have a leg ulcer.

Treating leg ulcers: Therapy for ulcus cruris venosum

Therapy for ulcus cruris venosum

When treating ulcus cruris venosum, it is important to treat the basic 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 creams, compression therapy with medical compression stockings or medical adaptive, i.e. adjustable, compression systems, as well as vein operations.

The medi therapy concept for the treatment of open wounds is based on the German principles of treatment of ulcus cruris venosum3 as well as “medical compression therapy”4: Effective products are adjusted to the individual phases of the therapy. See below.

For the doctor: Wound cleansing, treatment of the underlying illness, relapse prevention

Here you will find all the information about treatment3.4 of ulcus cruris venosum using compression therapy that complies with the guidelines: Compression supports the venous return blood flow, reduces the pressure and volume congestion in the leg vein system and alleviates pain.5,6

Duration of the healing process: This depends on many factors

If the treatment takes place according to 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 the treatment in accordance with the guidelines3.4 provides for compression treatment, 84 percent of those affected do not wear any compression during the active wound phase. Despite the proven effectiveness, insufficient or incorrect treatment for ulcus cruris venosum with regard to medical compression in compliance with the guidelines still continues today.1

After the ulcus cruris venosum 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 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 people for patients to contact if they have a leg ulcer. They work as doctors in their own medical practices, in hospitals and in special clinics.wie P
    • Certified wound advisers or wound managers are accredited nursing staff who have completed extra training. They work closely together with doctors and outpatient care services. The doctor always has overall responsibility for the treatment, however. That’s why a wound adviser can only be involved with the doctor’s agreement.
    • Outpatient care services are often an extension to GP services when caring for patients with chronic wounds. Some GPs also have team members who are trained in wound care.
    • Regional wound centres or outpatient clinics in hospitals employ expert teams to treat patients suffering from chronic wounds with dedication and a great deal of experience. There are around 40 wound care networks throughout Germany. Doctors, hospitals, care services and home care companies have set up an interdisciplinary range of 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:

Phase 1 - wound cleansing

wound cleansing

Only a clean wound can heal

Using UCS Debridement, a sterile compress that has already been pre-moistened with cleaning solution, wounds, the wound edge and wound environment can be cleaned and moistened in order to achieve better wound healing. This is because: Only a clean wound can heal.

Phase 2 – compression

So that the leg ulcer can heal

In the second phase of the therapy, medi offers an advantageous alternative therapy for ulcus cruris venosum: the adjustable compression care product circaid juxtacures.

    • circaid juxtacures are easy to adjust and apply – individually customised to the patient’s measurements, the product can be fastened and removed with the help of velcro straps.
    • Thanks to the integrated built-in pressure system, the compression pressure can be monitored – the required compression pressure can be set, checked and readjusted at any time.
    • Once the circumference of the leg has been reduced by drainage of the oedema, the circaid juxtacures can be adjusted to the new measurements.
    • When the oedema has been completely drained, the patient can switch to the ulcus stocking system mediven ulcer kit. This two-component system consists of an understocking with elemental silver for optimal hygiene and a discreet, round knit compression stocking.

Phase 3 – prophylaxis

So that the leg ulcer doesn't come back 

The basic disorder of chronic venous insufficiency chronic venous insufficiency still exists with ulcus cruris venosum, even after the wound has healed. In order to maintain the success of the therapy in the long term, use of medical compression stockings should be continued after the wound has healed.

For the time after the wound has healed, a large selection of mediven compression stockings in a wide variety of colours and styles is available to the patient. In patients with an additional disorder of the lymphatic vessel system and therefore a tendency to develop lymphoedema, flat knit compression stockings (such as mediven 550 leg) are the perfect choice.

If the patient is prone to venous-related swelling, or phleboedema, round knit compression stockings (such as mediven forte) should be worn. This means that every patient can receive customised care to maintain the therapy success in the long term.

Sources

1Sauer K. et al. (2014): Barmer GEK Heil- und Hilfsmittelreport 2014.
2 Rabe E et al. Bonner Venenstudie der Deutschen Gesellschaft für Phlebologie*. Epidemiologische Untersuchung zur Frage der Häufigkeit und Ausprägung von chronischen Venenkrankheiten in der städtischen und ländlichen Wohnbevölkerung. Phlebologie 2003;32:1-14.
3S3-Leitlinie "Diagnostik und Therapie des Ulcus cruris venosum" der Deutschen Gesellschaft für Phlebologie; Stand 2008.
4Rabe E et al. S2k-Leitlinie: Medizinische Kompressionstherapie der Extremitäten mit Medizinischem Kompressionsstrumpf (MKS), Phlebologischem Kompressionsverband (PKV) und Medizinischen adaptiven Kompressionssystemen (MAK). Online veröffentlicht unter: https://www.awmf.org/leitlinien/detail/ll/037-005.html (Letzter Zugriff 13.05.2019).
5Dissemond J et al. Kompressionstherapie des Ulcus cruris. Hautarzt 2016;67(4):311–325.
6Partsch H, Mortimer P. Compression for leg wounds. Br J Dermatol 2015;173(2):359–369.

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Treating wounds with compression therapy

When wounds won't heal

Help for venous leg ulcer

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