Finding the cause: Chronic leg ulcers demand proper diagnosis

Key Points

San Francisco - Properly diagnosing the cause or causes of chronic leg wounds provides the key to treating them, although physicians sometimes skip this step, an expert says.

"The minimum standard diagnostic workup that we should do with every leg ulcer patient includes a basic vascular investigation," using tools such as handheld continuous-wave Doppler scanning to determine if the patient suffers from superficial venous insufficiency, deep venous insufficiency or perhaps both, Dr. Laeuchli says.

In cases of superficial venous insufficiency, he says, it is advantageous to combine compression therapy with surgical removal of the culprit vein. In the latter area, a recent 500-patient study has shown that compression alone yields a four-year recurrence rate of 56 percent, versus 30 percent for compression and saphenous surgery (Gohel HS et al. BMJ. 2007 Jul 14;335(7610):83. Epub 2007 Jun 1).

Other treatment options for venous hypertension include pharmacologic therapy and sclerotherapy.

To rule out arterial ulcers, Dr. Laeuchli recommends investigating pedal pulse, ankle systolic pressure and ankle brachial pressure index. Only selected complex cases will need measurement of toe systolic pressure and tcPO₂, as well as duplex Doppler scanning and angiography.

Intervention options for arterial ulcers include vascular surgery, angioplasty, iloprost and exercise, while secondary prevention measures include controlling risk factors and perhaps using anti-thrombotic or rheologic drugs, he says.

For mixed venous-arterial ulcers, he adds, treatment begins with revascularization, followed by compression and, if indicated, saphenous surgery, and, in many cases, advanced wound healing methods such as vacuum-assisted closure (VAC) and split-thickness skin grafts.

Another key diagnostic element for nonhealing ulcers involves deciding whether biopsy and histologic analysis are indicated. Without these tools, Dr. Laeuchli says, physicians might mistake skin tumors, such as basal or squamous cell carcinomas, for leg ulcers.

"If an ulcer doesn't heal for six months - and some experts say three months - it should be biopsied to rule out cancer," he says.

Dermatologists also are trained to recognize the rare causes for ulcers, which occur in about 10 percent of cases (Baker SR et al. Eur J Vasc Surg. 1992 May;6(3):245-51), Dr. Laeuchli says.