A skin ulcer develops when an area of skin breaks down to reveal the underlying flesh. Venous leg ulcers are the most common type of skin ulcer. They mainly occur just above the ankle. They usually affect older people and are more common in women. They affect about 1 in 1,000 people in the UK at some stage in their lives. Venous leg ulcers become more common as you get older and 20 in 1,000 people become affected by the time they are in their 80s. Most are painless but some are painful. Without treatment, an ulcer may become larger and cause problems in the leg. Skin inflammation (dermatitis) sometimes develops around a venous ulcer.
Non-venous skin ulcers are less common. For example, a skin ulcer may be caused by poor circulation due to narrowed arteries in the leg, problems with nerves that supply the skin, or other problems. The treatment for non-venous ulcers is different to that of venous ulcers.
The root of the problem is increased pressure of blood in the veins of the lower leg. This causes fluid to ooze out of the veins beneath the skin. This causes swelling, thickening and damage to the skin. The damaged skin may eventually break down to form an ulcer.
The increased pressure of blood in the leg veins is due to blood collecting in the smaller veins next to the skin. The blood tends to collect and pool because the valves in the larger veins become damaged by a previous blood clot (thrombosis) in the vein, or varicose veins. Gravity causes blood to flow back through the damaged valves and pool in the lower veins.
The appearance of a venous leg ulcer is usually fairly typical. It often looks different to ulcers caused by other problems such as poor circulation or nerve problems.
To rule out poor circulation as a cause, it is usual for a doctor or nurse to check the blood pressure in the ankle and in the arm. The ankle blood pressure reading is divided by the arm blood pressure reading to give a blood pressure ratio called the Ankle Brachial Pressure Index (ABPI). If the ratio is low (less than 0.8) it indicates that the cause of the ulcer is likely to be poor circulation (peripheral arterial disease) rather than venous problems. This is very important to know as the treatments are very different. An ABPI may be checked every six months or so to make sure the circulation to the legs remains good.
Certain blood and urine tests may also be done to rule out conditions such as anaemia, diabetes, kidney problems and rheumatoid arthritis, which may cause or aggravate certain types of skin ulcer. In complicated cases you may need to have an ultrasound scan, CT scan or MRI scan to produce a detailed map of the blood circulation in your leg.
The ulcer is dressed in a similar way to any other wound. Typically, a nurse will do this every week or so. The wound is cleaned when the dressing is changed - normally with ordinary tap water. However, an ulcer is unlikely to heal with just dressings. In addition to a dressing, the following treatments help the ulcer to heal.
This is the most important part of treatment. The aim is to counteract the raised pressure in the leg veins. This gives the best chance for the ulcer to heal. The common method is for a nurse to put on 2-4 layers of bandages over the dressing. When the bandages are put on, the pressure is put highest at the ankle and gradually less towards the knee and thigh. A support (compression) stocking over the dressing is sometimes used as an alternative but not thought to be as good as bandaging.
The bandages are reapplied every week or so. It is best to put the bandages on after you have raised (elevated) the leg for several hours or overnight (see below). So, make extra effort to keep your leg elevated just before the nurse is due to see you.
A note of caution: when you have a compression bandage on you should still be able to move your ankle around. Occasionally, the compression is too tight, or it may affect the circulation in the legs. Therefore, take off the bandages if your foot changes color or temperature, or if you have increasing pain. Then see your doctor or nurse for advice.
When you are resting, if possible, try to keep your leg raised higher than your hip. This is particularly important if your leg is swollen. The aim is to let gravity help to pull fluid and blood in the right direction - towards the heart. This reduces swelling in the leg and reduces the pressure of blood in the leg veins. Try to set 3 or 4 periods per day of about 30 minutes to lie down with your leg raised. For example, lie on a bed or sofa with your foot on a couple of pillows. However, do not spend all your time in bed or resting. For the rest of the time, keep as active as you can and do normal activities. If possible, regular walks are good but do not stand still for long periods.
When you sleep overnight, if possible, try to keep your leg raised. You can do this by putting some pillows under the bottom of the mattress. (It may not be possible to sleep like this if you have certain other medical problems or disabilities.)
In some people, other conditions such as anemia, poor nutrition, swelling of the legs and other medical problems may mean that the skin has less chance of healing well. Other treatments may be needed to help heal a venous leg ulcer - for example:
• Try to stop smoking if you are a smoker. The chemicals in cigarettes may interfere with the skin healing.
• Antibiotic medicines are sometimes advised for short periods if the skin and tissues around the ulcer become infected.
• Painkillers can be taken if the ulcer is painful.
• Skin care. The skin around an ulcer is often inflamed or scaly. Your doctor or nurse may advise on a cream to reduce inflammation if necessary.
• Dietary advice if your diet is not very good. Also, if you are overweight then losing some weight may help. Obesity is a risk factor for developing venous leg ulcers.
• Iron tablets or other treatments if you are anaemic.
• Pentoxifylline improves blood circulation and you may be offered this medicine to promote healing of the ulcer.
• Hyperbaric oxygen (oxygen delivered at high pressure) is sometimes used when facilities are available.
• A skin graft may be advised for a large ulcer, or for one that does not heal well.
• Surgery for varicose veins or other vein problems is advised in some cases. This may correct back pressure of blood pooling in the veins and allow an ulcer to heal.
In the past, patients suffering from varicose veins only had one treatment option, and that is to undergo surgery to remove the affected veins from the legs. This surgery, which is called vein "stripping", has many risks including the risk of infection, allergic reaction to anesthesia and risk of heavy blooding, among others. Some patients even report seeing new varicose veins appear months after the operation.
Luckily, medical research has led to new breakthroughs in the treatment of varicose veins that are less invasive and carries fewer risks. As such, treatments are now safer and more effective, giving patients the option to get relief from the pain of having spider veins without having to undergo painful surgery.
One of the safer options for varicose patients is Microphlebectomy, also known as ambulatory phlebectomy. Microphlebectomy is a medical procedure that is used to remove large surface or medium-sized varicose veins. It is often done in conjunction with endovenous laser ablation to permanently relieve the symptoms of varicose veins and improve the appearance of your legs. It is the preferred treatment when the varicose veins to be removed are too big or too small to treat with other varicose vein procedures.
Who can undergo the procedure?
To know whether you are a good candidate for this procedure, it is best to undergo a proper evaluation, during which you can discuss your medical history with your physician. During your consultation, your physician will determine whether the varicose veins are the only concern, or whether other connected veins need to be addressed as well. The clots in your veins will also be evaluated to know whether they affect the deep veins or only the surface.
Patients who have an allergic reaction to local anesthesia and those who lack the ability to walk on their own are not good candidates for this procedure. If you have an active infection, it would be best to postpone the procedure until infection has been resolved.
How is Microphlebectomy performed?
Microphlebectomy is an outpatient procedure that is commonly done in a doctor's office. The procedure involves creating a series of small incisions in the skin around the vein, which will give your doctor access to the malfunctioning veins that need to be removed. This treatment does not require sutures - you will leave the doctor's office with only small bandages placed over the incision. While you are allowed to go back to normal activities a day after the operation, you will need to wear compression stockings for at least two weeks following the surgery to prevent blood clots from developing in the leg.
Microphlebectomy has several benefits over other varicose vein treatment:
• It is minimally invasive
• It requires little downtime, so you can return to your daily activities after the procedure
• Shorter recovery period
• Long-term results without visible scarring
• Performed on an outpatient basis
There are a number of different treatment options for varicose veins. Depending on the severity of the case, a surgery may be required to remove the affected veins. While some cases can be effectively managed through increased activity, a low-sodium diet, and leg elevation.
One of the frequently used methods for treating varicose veins is endovenous ablation. This is a minimally invasive procedure that uses radiofrequency energy to heat enlarged veins and cause them to collapse and close. Venous ablation is an alternative to vein stripping, a surgical procedure traditionally performed to remove the main vein in the leg.
Normally, the heart pumps oxygen-rich blood through the arteries and the rest of the body, including the legs. The blood then circulates back to the heart through a series of one-way valves found in the veins. When the valves leak and your veins stop working properly, blood can pool in the leg veins and cause them to be enlarged. This results in varicose or spider veins that often appear on the legs and thighs, but can also develop in other parts of the body.
The introduction of Venous ablation has given patients a viable option for a cosmetically superior procedure that does not leave visible scars. It is commonly utilized for the treatment of varicose veins, but can also be used for patients suffering from leg pain and other discomfort related to varicose veins and other venous conditions.
The procedure is done by inserting a thin catheter into the vein to treat it with radiofrequency energy or laser. To ensure that the laser is targeting the entire length of the vein, the physician performing the procedure uses an ultrasound monitor to track its path and visualize the veins. Once the vein's wall is "injured" by the laser or radiofrequency electrode, it will shrink and eventually turn into a scar tissue.
This safe procedure is useful for addressing the symptoms of varicose veins, as well as the cosmetic corners of patients suffering from the disease.
The benefits of Venous ablation:
• In most cases, venous ablation results in permanent removal of varicose veins because it effectively removes the refluxing source of the disease
• It offers immediate relief to patients who have undergone the procedure
• There will be no visible scarring as the procedure involves making a very small incision that does not have to be stitched closed
• It has fewer complications compared with vein stripping techniques
• After the procedure, patients can return to normal activities with little to no pain in the treated area
• The procedure does not require an overnight stay in a hospital
Sclerotherapy is a procedure that effectively treats varicose and spider veins. The procedure has been around since the 1930s and is often considered the treatment of choice for improving the appearance of such veins. Sclerotherapy has also been proven to help with related symptoms such as aching, swelling, burning, and/or night cramps.
The procedure is done by injecting a salt/irritating solution directly in to the vein. At this point the patient might experience mild discomfort or itching of the leg for a few minutes. What the solution does is cause the vein to swell and the blood to stick together. The vein then scars, which forces blood to reroute through healthier veins. The old, collapsed vein is reabsorbed into local tissue and overtime will fade out of view. This process can take only a few short weeks, but in some cases several treatments may be needed, and the process could take a few months. Studies have shown that 60-80% of veins that have undergone sclerotherapy are eliminated.
Sclerotherapy is a safe procedure with few complications, but not everyone is a candidate for this type of procedure. If you are pregnant or breast feeding, it is recommended to wait to have this procedure. If you have had a blood clot in the past, your eligibility will depend on overall health as well as the reason for past clots. Also, veins that could potentially be used for future heart bypass surgery are typically not eligible for sclerotherapy.
Before the procedure you will undergo a physical exam and check your medical history. Depending on which veins are involved you may be asked to have an ultrasound to gain better image of the veins. The day before avoid shaving or applying lotion to the legs. Wear comfortable clothing, such as a pair of shorts so that your legs are exposed. The procedure doesn’t require any anesthesia and normally takes less than an hour to complete. After the procedure you’ll be able to move around so as to prevent any blood clots from forming. Compression stockings or bandages will be required for a couple of weeks. Most people return to their normal activities on the same day as the treatment, but strenuous exercise should be avoided for up to two weeks post-procedure.
Vascular ultrasound is a noninvasive method used to evaluate the blood circulation of vessels in the body. It can be used to examine arteries and veins in nearly every part of the body, and more importantly helps detect blockages, such as blood clots. A doppler ultrasound study is usually part of this procedure. This ultrasound evaluates specific blood flow through a blood vessel. Vascular ultrasound uses no radiation exposure, therefore having no harmful effects. It requires little to no special preparation, and ultimately provides images of soft tissues that don’t show up on x-ray images.
The procedure involves the use of a small transducer (probe) and ultrasound gel placed directly on the skin to create high-frequency sound waves that will be used to create an image that shows up on the computer screen. The images are captured in real-time, thus giving the most accurate depiction of the movement of the body’s organs and blood vessels. Generally, this procedure takes between 30-45 minutes.
Some common uses for this type of procedure:
• Identify blockages (stenosis) and abnormalities
• Detect blood clots
• Evaluate varicose veins
• Determine where a patient is a good candidate for other procedures
• Evaluate the success of other procedures
• Help monitor blood flow to organs and tissues
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