Lower

Extremity
Ulcer
Bagus Andi Pramono
Supervisors:
dr. Hariadi Hariawan, SpPD, SpJPK
Dr. dr. Budi Yuli Setianto, SpPDK, SpJPK
Background
Chronic ulceration of the lower leg is a frequent condition,
with a prevalence of 35% in the population over 65 years of
age.
The incidence of ulceration is rising as a result of the ageing
population and increased risk factors for atherosclerotic
occlusion such as smoking, obesity and diabetes.
A leg ulcer is a loss of skin below the knee in the leg or foot which takes
more than 4 - 6 weeks to heal
Mekkes et al., 2003
Background
An appreciation of evidence-based treatment pathways
and an understanding of the pathophysiology of chronic
wounds are important elements in the management of
patients with chronic wounds
Vascular contribution in ulcer pathogenesis
Common causes
Venous insufficiency (post-thrombotic syndrome)
Peripheral arterial disease (arteriosclerosis)
Diabetes (neuropathy and or arterial occlusion)
Decubitus (pressure)
Infection (mostly Streptococcus haemolyticus)
Vasculitis (small vessel leucocytoclastic vasculitis)
Mekkes et al., 2003
Leg ulcers Causes

Poor circulation, often caused by arteriosclerosis
Venous insufficiency (a failure of the valves in the veins of the leg that
causes congestion and slowing of blood circulation in the veins)
Other disorders of clotting and circulation that may or may not be related
to atherosclerosis
Diabetes
Renal (kidney) failure
Hypertension (treated or untreated)
Lymphedema (a buildup of fluid that causes swelling in the legs or feet)
Inflammatory diseases including vasculitis, lupus, scleroderma or other
rheumatological conditions
Other medical conditions such as high cholesterol, heart disease, high
blood pressure, sickle cell anemia, bowel disorders
History of smoking (either current or past)
Pressure caused by lying in one position for too long
Genetics (ulcers may be hereditary)
A malignancy (tumor or cancerous mass)
Infections
Certain medications
Percentage
81%
10%
7%
1%
1%
1%
Causes
Venous
Arterial
Mixed
Diabetic
Malignancy
Rheumatoid
O Brien et al., 2000
Philips et al, 1991
Venous ulcers
Venous ulcer

History of venous disease DVTs
Recurrent
Painless
Signs of venous hypertension
Haemosiderin
Lipodermatoclerosis
Eczema
Flares/spider nevi
Note :
Normal ABIs
Painless
Tierney, 2009
Commonly noted in the
"gaiter" region of the legs.
Larger but shallower
Moist granulating base,
irregular border.
This base oozes venous
blood when manipulated.
The tissue surrounding these
ulcers may exhibit signs of
stasis dermatitis.
mild pain that is relieved by
elevation.
Venous ulcers
Gabriel, 2012
Arterial ulcers

Atherosclerosis
Skin crack
Arterial embolization
Inadequate
perfusion
Ulcer
Ischemia
Necrotic tissue
Mekkes et al., 2003
Arterial
History of intermittent claudication
Pain
Absent pulses
Reduced ABIs

Beware
Colour
Temperature
Capillary filling unreliable

Tierney, 2009
Located distally and on the dorsum of the foot or
toes.
Irregular edges a better-defined appearance.
Grayish, unhealthy-appearing granulation tissue.
Debriding bleed very little or not at all.
Characteristic pain
Characteristic findings of chronic ischemia
(hairlessness, pale skin, and absent pulses)
Gabriel, 2012
Anders et al., 2010
Wong, 2014
Chadwick et al., 2013
Pressure
Neuropathic
Chadwick et al., 2013
Management

Debridement
Pressure control
Infection control
Exudate management
Mustoe et al., 2006
TIME framework

Tissue debridement
Inflammation and infection control
Moisture balance (optimal dressing selection)
Epithelial edge advancement
Chadwick et al., 2013
Debridement

Methods of debridement used including surgical/sharp, larval,
autolytic and, more recently, hydrosurgery and ultrasonic
The requirement for further debridement should be determined at
each dressing change.
No one debridement method has been shown to be more effective
in achieving complete ulcer healing
Removes necrotic/sloughy tissue and callus
Reduces pressure, allows full inspection of the underlying tissues
Helps drainage of secretions or pus
Helps optimise the effectiveness of topical preparations
Stimulates healing
Chadwick et al., 2013
Pressure control

The key to the successful healing of chronic venous ulcers will be to
correct the underlying venous hypertension using graduated
compression therapy

Education for patients regarding the need for life long support of
the veins in their legs is paramount and should be emphasised from
the beginning of treatment.
Several different types of bandaging systems are available, each of
which may have advantages over the others for particular
applications.
EWMA, 2003; Moffatt, 2007
Infection control

Start empiric oral antibiotic therapy targeted at Staphylococcus
aureus and -haemolytic Streptococcus
Change to an alternate antibiotic if the culture results indicate a
more appropriate antibiotic
Obtain another optimum specimen for culture if the wound does
not respond to treatment.
Topical antimicrobials benefit in:
Concerns regarding reduced antibiotic tissue penetration
poor vascular supply
clinical suspicion of increased bacterial bioburden
Chadwick et al., 2013
Common topical antimicrobial agents

Silver dressings containing silver (elemental, inorganic
compound or organic complex) or silver sulphadiazine cream/
dressings
Polyhexamethylene biguanide (PHMB) solution, gel or
impregnated dressings
Iodine povidone iodine (impregnated dressing) or cadexomer
iodine (ointment, beads or impregnated dressings)
Medical-grade honey gel, ointment or impregnated dressings
Topical antimicrobial agents should not be used alone in those with
clinical signs of infection
Chadwick et al., 2013
Exudate management

Dressings that can help to manage wound exudate optimally and
promote a balanced environment are key to improving outcomes
Consider :
Location of the wound
Extent (size/depth) of the wound
Amount and type of exudate
The predominant tissue type on the wound surface
Condition of the periwound skin
Compatibility with other therapies (eg contact casts)
Wound bioburden and risk of infection
Avoidance of pain and trauma at dressing changes
Quality of life and patient wellbeing
Chadwick et al., 2013
The best dressing

There is no consensus about the best agent.
The method of debridement chosen may depend on the status of
the wound, the capability of the healthcare provider and the
overall condition of the patient.
It is common to combine methods of debridement in
order to maximize the healing rates.
Barbul, 2007
Adjunctive therapy

Considered when needed and available
Ulcers not healed with conventional therapy
Growth factor (PDGF, GCSF)
Negative pressure wound therapy
Biological dressing
Bioenginered skin equivalent
Hyperbaric oxygen therapy
Platelet rich plasma
Greer, 2012
Conclusions
Knowledge about etiology and pathophysiology of
the lower extremity ulcers is needed to manage
patients with ulcer in lower extremity;
Vascular contribution plays major role in the ulcer of
the lower extremity;
Three important components of ulcer management
: treat the causes, treat persons related complaints,
treat the wound
Chadwick et al., 2013
Gist, 2009
Stages of chronic venous
insufficiency
(Expert meeting in Moscow, 2000.)
0 - no symptoms;
1 - heavy feet syndrome;
2 - intermittent edema;
3 - persistent edema, hyper- or
hypopigmentation, lipodermatosclerosis,
eczema;
4 - venous ulcer.