Lower Extremity (Leg and Foot) Ulcers

Lower Extremity (Leg and Foot) Ulcers

What are ulcers?

Ulcers are wounds or open sores that will not heal or keep returning.

What are the symptoms of ulcers?

Ulcers may or may not be painful. The patient generally has a swollen leg and may feel burning or itching. There may also be a rash, redness, brown discoloration or dry, scaly skin.

What are the types of leg and foot ulcers?

The three most common types of leg and foot ulcers include:

• Venous statis ulcers


• Neurotrophic (diabetic)


• Arterial (ischemic ulcers)

Ulcers are typically defined by the appearance of the ulcer, the ulcer location, and the way the borders and surrounding skin of the ulcer look.

Neuropathy and peripheral artery disease often occur together in people who have diabetes. Nerve damage (neuropathy) in the feet can result in a loss of foot sensation and changes in the sweat-producing glands, increasing the risk of being unaware of foot calluses or cracks, injury or risk of infection. Symptoms of neuropathy include tingling, numbness, burning or pain.

It is easy to understand why people with diabetes are more prone to foot ulcers than other patients. This is why people with diabetes need to inspect their feet daily and wear appropriate footwear. People with diabetes should never walk barefoot.

What causes leg ulcers?

Leg ulcers may be caused by medical conditions such as:

• 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

How are leg ulcers diagnosed?

First, the patient's medical history is evaluated. A wound specialist will examine the wound thoroughly and may perform tests such as X-rays, MRIs, CT scans and noninvasive vascular studies to help develop a treatment plan.

How are leg ulcers treated?

At Cleveland Clinic, patients are treated by a team of world-class experts in the Lower Extremity Wound Clinic in the Department of Vascular Medicine. This Clinic includes doctors, nurses and other medical specialists.

These experts work together to determine the cause of the ulcer and develop an individualized treatment program.

The goals of treatment are to relieve pain, speed recovery and heal the wound. Each patient's treatment plan is individualized, based on the patient's health, medical condition and ability to care for the wound.

Treatment options for all ulcers may include:

• Antibiotics, if an infection is present


• Anti-platelet or anti-clotting medications to prevent a blood clot


• Topical wound care therapies


• Compression garments


• Prosthetics or orthotics, available to restore or enhance normal lifestyle function

Venous Ulcer Treatment

Venous ulcers are treated with compression of the leg to minimize edema or swelling. Compression treatments include wearing compression stockings, multi-layer compression wraps, or wrapping an ACE bandage or dressing from the toes or foot to the area below the knee. The type of compression treatment prescribed is determined by the physician, based on the characteristics of the ulcer base and amount of drainage from the ulcer.

The type of dressing prescribed for ulcers is determined by the type of ulcer and the appearance at the base of the ulcer. Types of dressings include:

• Moist to moist dressings


• Hydrogels/hydrocolloids


• Alginate dressings


• Collagen wound dressings


• Debriding agents


• Antimicrobial dressings


• Composite dressings


• Synthetic skin substitutes

Arterial Ulcer Treatment

Arterial ulcer treatments vary, depending on the severity of the arterial disease. Non-invasive vascular tests provide the physician with the diagnostic tools to assess the potential for wound healing. Depending on the patient's condition, the physician may recommend invasive testing, endovascular therapy or bypass surgery to restore circulation to the affected leg.

The goals for arterial ulcer treatment include:

• Providing adequate protection of the surface of the skin


• Preventing new ulcers


• Removing contact irritation to the existing ulcer


• Monitoring signs and symptoms of infection that may involve the soft tissues or bone

Treatment for neurotrophic ulcers includes avoiding pressure and weight-bearing on the affected leg. Regular debridement (the removal of infected tissue) is usually necessary before a neurotrophic ulcer can heal. Frequently, special shoes or orthotic devices must be worn.

Wound Care at Home

Patients are given instructions to care for their wounds at home. These instructions include:

• Keeping the wound clean and dry


• Changing the dressing as directed


• Taking prescribed medications as directed


• Drinking plenty of fluid


• Following a healthy diet, as recommended, including plenty of fruits and vegetables


• Exercising regularly, as directed by a physician


• Wearing appropriate shoes


• Wearing compression wraps, if appropriate, as directed

How can ulcers be prevented?

Controlling risk factors can help you prevent ulcers from developing or getting worse. Here are some ways to reduce your risk factors:

• Quit smoking


• Manage your blood pressure


• Control your blood cholesterol and triglyceride levels by making dietary changes and taking medications as prescribed


• Limit your intake of sodium


• Manage your diabetes and other health conditions, if applicable


• Exercise – start a walking program after speaking with your doctor


• Lose weight if you are overweight


• Ask your doctor about aspirin therapy to prevent blood clots

Reference:  http://my.clevelandclinic.org/heart/disorders/vascular/legfootulcer.aspx