Leg, foot wounds and ulcers

National report - Every experienced dermatologist and clinician is well aware of the challenges faced when treating leg and foot ulcers due to venous or arterial abnormalities or diabetic ulcers with neuropathic or ischemic backgrounds.

Therapies are arduous and protracted, and positive outcomes are sometimes difficult to achieve, says O. Fred Miller, III, M.D., emeritus director of the department of dermatology at the Geisinger Medical Center in Danville, Pa.

Dr. Miller shares his experience and insight on lower extremity and foot ulcers, and their management and the current treatment modalities used.

Treating leg and foot ulcers is a very challenging task for any experienced dermatologist.

There are various etiologies causing these ulcers, with venous abnormalities accounting for 80 percent of cases, affecting 0.6 percent of Western populations. Other common causes of ulcers include arterial (peripheral vascular disease), neuropathic (diabetes), mixed, pressure (heel), infectious, malignancy, traumatic and factitial.

Statistically, 5 to 8 percent of the world's population suffers from venous disease. In the United States, 5 million people suffer from venous insufficiency. Approximately 500,000 have venous ulcers, and each ulcer will cost a stunning $9,000 to treat and heal.

Therapeutic points

Dr. Miller says there are four basic points in ulcer therapy.

Dr. Miller says that the typical symptoms of a venous ulcer are aching or pain often relieved by elevation of the extremity, with or without a history of a deep vein thrombosis. They commonly appear on the medial leg between 1 cm below the malleolus and calf muscle prominence, and are usually irregularly shaped and shallow with granulation tissue and fibrinous slough at the base. There is usually a swelling of the ankle/leg (nonpitting edema) and the skin is tender on palpation. Hemosiderin pigmentation is commonly present, with or without dermatitis, and repeated inflammation of the area will ultimately cause a secondary lymphedema of the leg. Here, a venous duplex sonography is an invaluable tool in diagnosing incompetent perforating veins or a deep vein thrombosis, which can be life threatening.

Therapy options

Dr. Miller says that diuretics are ineffective for nonpitting edema, but a compression boot (Unna boot, Kendall) is very helpful here.

Skincare consists of topical steroids under occlusion, or a course of systemic tapered steroids can be tried. Debridement of the necrotic and fibrinous tissue is of paramount importance, allowing the new granulation tissue to thrive. This can be achieved mechanically with a scissor or a knife, through autolysis employing hydrocolloids (e.g., Duoderm, ConvaTec), or by applying proteolytics to the wound.

Also, moist to moist saline gauze (not wet to dry saline gauze) is very beneficial for wound maintenance and healing. Dr. Miller stresses that wound cleansing should only be done with saline, and that physicians should avoid betadine, hydrogen peroxide and hexachlorophene solutions. When a "healed state" is achieved, patients are advised to wear the sometimes uncomfortable, yet very effective, elastic stockings with a compression of 30 mm Hg to 40 mm Hg.

Optimizing therapy

Dr. Miller offers some pearls on how to optimize ulcer therapy.