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LEG ULCERS AND PRESSURE SORES

 Leg Ulcers

Leg ulceration is a chronic disease occurring predominantly in the older population.  An ulcer can be defined as a local deficit or excavation of the surface of an organ or tissue, which is produced by the sloughing inflammatory necrotic tissue.  Ulcers can be present for many years and are resistant to healing, not infrequently due to inappropriate treatment resulting from an inadequate medical assessment.  Estimates of prevalence range from 1.5 to 1.8 per 1000 total population, rising to 3 per 1000 at age 61-70 and to 20 per 1000 in people aged 80 and over.  The annual cost to the National Health Service is estimated to be in the region of £300-600 million.  The majority of patients are cared for by community services.

Causes and Symptoms

Venous ulcers account for 70-90% of all cases.  Arterial ulcers account for 5-20% of cases.  Combined venous hypertension and arterial disease account for 10-15% of cases.  Less common causes account for 5-10% of cases and include: diabetes, vasculitis, neoplasm, infection and trauma and other specific causes.

Venous ulceration can result from chronic venous hypertension in the lower limb, usually due to malfunctioning valves in the leg veins, of either congenital or acquired origin, resulting in a blackflow of blood.  The superficial venous network is exposed to higher pressures than normal resulting in oedema, capillary damage and thinning of the dermis (inner layer of the skin containing vessels, nerves and fibrous tissue – covered by the epidermis).  The subsequent leakage of red blood cells and large protein molecules creates the physiological conditions which can lead to ulcer formation.  Varicosities (abnormal swelling of veins) are commonly present.  Often the lower limb is swollen with a brown discoloration of the skin and the prescence of an irritating eczema.

Arterial ulcers result from a reduced arterial circulation.  Common causes include atherosclerotic changed in the main vessels and small emboli (blockages), not uncommonly the result of hypertension.  Smoking and poor diet are contributory factors.  The lower limb may appear pale or a dusky red colour and the patient commonly complains of pain, particularly when the limb is elevated or during exercise.

Leg ulceration impacts on the quality of daily life through pain, physical restrictions, sleep disturbances, reduced energy, emotional reactions and social isolation.

Treatments

Venous ulceration – treatment aims to counteract the high pressure in the superficial veins, increase the calf muscle pump mechanism to assist venous return and reduce oedema.  This is achieved by applying graduated compression from the toes to the knee.  Local wound management aims to achieve optimum healing conditions and avoid the exacerbation of varicose eczema.  Underlying nutritional deficiencies should be corrected.  The prognosis is good, providing the cause of the ulcer has been correctly assessed and management decisions have involved patient consultation.  Support or compression hosiery is often necessary to prevent recurrence following healing.

Arterial ulceration – treatment includes the local management of the wound and avoids compression, which would exacerbate the arterial insufficiency.  Vasodilator drugs may be used.  The prognosis is poor, unless surgical intervention is possible to correct the arterial problems.  Cessation of smoking, weight control, a nutritious diet and maintaining mobility are beneficial.

 Pressure Sores

A pressure sore is an area of damaged skin and tissue caused by unrelieved pressure, shear or friction, typically sustained during long periods of bed or chair rest during illness or disability.  Prevalence rates are estimated at between 7% and 10% in hospital and community patients.   Treatment is aimed towards prevention, including relief of the pressure and avoidance of friction and shear forces.  There are many pressure relieving aids available and methods of care aimed at prevention.  Damaged skin should be covered with suitable dressing. Pressure sores do happen in spite the care  of dedicated nurses. Prevention is the most important step as in most diseases. Treatment is directed at relieving pressure and local wound dressings.