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Introduction

Chronic wounds are common, disproportionately affect older adults, and are likely to be encountered by healthcare providers across all specialties and care settings. All healthcare providers should know basic wound prevention strategies, identification, classification, and treatment approaches. Leg ulcers affect patients in all care settings and result in significant cost, poor quality of life, decreased mobility, and morbidity. The burden of this condition falls largely on older adults. Medicare costs for wound care in 2014 were estimated at over $28 billion (9). Venous ulcers are the most common lower extremity wound type, comprising 45% to 60% of all wounds, followed by neuropathic ulcers (15% to 25%) and ischemic ulcers (10% to 20%) (9). 

This learning module will discuss the three most common types of leg/foot ulcers: venous stasis ulcers, neuropathic (diabetic), and arterial (ischemic ulcers). Additionally, we will cover the main differences between arterial vs. venous ulcers, as this can sometimes become quite confusing. Following, we will review the circulatory system’s pathophysiology, ensuring an understanding of blood flow and the vital role arteries and veins have on circulation. Lastly, we will discuss the presentations of each type, the common causes, risk factors, generalized treatments, and patient education.  

As you work through the section questions, I hope you will be able to recall some patients you have cared for and better understand why the wounds presented as they did.  

Okay, let’s get started!  

Circulatory Pathophysiology Review 

Pulmonary circulation is responsible for circulating oxygen-poor blood from the heart’s right ventricle to the lungs via the pulmonary artery and then returning oxygen-rich blood back to the heart’s left atrium via the pulmonary vein (3). 

Systemic circulation is responsible for circulating the oxygenated blood from the heart to all the body systems. It carries oxygenated blood from the left ventricle through arteries to the capillaries in the body’s tissues. It carries oxygen and nutrients to the cells and picks up carbon dioxide and waste products.  

The vascular system supplies oxygen to the body and removes water through 5 types of blood vessels (arteries, arterioles, veins, venules, and capillaries (the smallest vessels- linking arterioles and venules). 

Venous Ulcers 

Pathophysiology

Venous ulcers begin due to capillary bed distention caused by increased pressure, causing fibrinogen leakage and eventually impeding the delivery of oxygen and nutrients, resulting in a hypoxic injury. Typically, this leads to fibrosis and then ulcerations. Venous leg ulcers are late indicators of chronic venous insufficiency and venous hypertension. Venous ulcers, also known as venous stasis or nonhealing wounds, are often found around the ankle or lower leg (1). Familiar with people with a previous history of varicose veins or leg swelling (1).  

These ulcers are often chronic, and patients usually battle from weeks to years. They frequently cause 60-80% of all leg ulcerations (2). Their 3-month healing rate is estimated at 40%, and once healed, up to 80% of patients develop a reoccurrence within three months (2). Their prevalence and incidence increase with age because of age’s adverse effects on healing, recurrence, and treatment adherence (2). Even with proper treatment, 20% will not heal after two years. The financial and social burden of venous ulcers is estimated to be $32 billion annually in the United States (2).  

A common mishap is the confusion between arterial vs. venous ulcers, so let’s break them down individually by signs and symptoms, complications, risk factors, treatments, and patient education.  

Causes (1) 

Venous ulcers occur because of poor blood flow in veins in the legs. The valves that control the blood flow through the veins can be damaged, altering blood flow and leading to ulcers. The body has trouble healing without adequate blood flow, causing ulcers to develop and linger. They often form because of an underlying issue that reduces wound healing or damages the skin, such as: 

• Venous hypertension  

• Venous insufficiency 

• Varicose veins 

• Blood clots 

• Poor circulation  

• Diabetes, kidney failure, or inflammatory diseases  

• Certain medications 

• Infections 

• Obesity 

Signs and Symptoms (1) 

• Wounds are usually located below the knee and can be one or both legs 

• Shallow, painful ulcerations usually over the medial malleolus 

• The wound bed is beefy red and often has fibrin present 

• Borders are irregular, and surrounding tissue is often discolored and swollen (can even feel warm) 

• Skin usually appears shiny and tight depending on edema  

• Elevation improves edema and relieves pain 

• Normal pulses are present  

• Drainage and discharge 

Complications (1)

• Cellulitis  

• Osteomyelitis 

• Sepsis  

• Amputation  

Risk Factors (1)

• Poor Circulation  

• Venous insufficiency 

• Clotting disorders 

• Old age 

• Sitting for long periods with legs dangling or positioned below the heart 

• Elevated cholesterol and triglycerides 

• Lymphedema 

• Obesity 

• Infections 

• Smoking 

• Uncontrolled hypertension 

• Standing for prolonged periods 

• Uncontrolled swelling 

• History of venous ulcers 

• Trauma due to fracture or burn 

• Sedentary lifestyle  

• Family history 

Treatments

Compression treatments are the most widely used treatment for venous stasis ulcers. This could include ace wraps, compression stockings, and Unna boots. Other treatments include vein ablation, sclerotherapy (shots), or a phlebectomy. New medications that use growth factors are currently being studied, which will promote the growth of new tissue (1). Venous ulcers that are severe and do not respond to traditional treatments may require additional treatments such as hyperbaric oxygen therapy, lymphedema therapy, skin grafts, stem cell therapy, or venous disease treatment (7).  

Dressings are ordered based on wound characteristics (do we need to dry the wound or add moisture). Dressings may include: 

• Moist to moist dressings 

• Hydrogels/hydrocolloids 

• Alginate dressings 

• Collagen wound dressings 

• Debriding agents 

• Antimicrobial dressings 

• Composite dressings 

Patient Education

Patient education focuses on prevention measures and on how to ensure proper healing of ulcers. Preventing vein problems is key to preventing ulcers. Healthy habits that help promote blood flow in the legs can help. Lifestyle changes can improve circulation and reduce the risk of venous ulcers.  

• Inspect your feet and between your toes; look for cracks, cuts, blisters, redness, increased warmth, and calluses. 

• If you have diabetes, see a podiatrist regularly. 

• Apply a lanolin-based cream to your legs and feet to prevent dry skin and cracking. Do not apply lotion between your toes or on areas with open sores or cuts.  

• If you have an open area, gently wash with mild soap and water daily; washing helps loosen dead skin and debris. 

• Elevate legs often and avoid sitting with legs dangling 

• If you cut your toenails, do it after bathing when the nails are soft and cut straight across 

• Maintain healthy weight  

• Quit smoking and using tobacco products 

• Eat a healthy diet with fruits, veggies, and protein 

Arterial (Ischemic) Ulcers 

Pathophysiology

Arterial leg ulcers account for around 22% of ulcers and occur because of poor blood supply to the legs. The two most common causes of arterial (or ischemic) ulcers are progressive atherosclerosis and emboli. Other pathologic processes can cause arterial obstruction, leading to arterial insufficiency symptoms. However, the reason for all the issues is reduced blood flow, which leads to ischemia in the affected extremity. Arteries carry oxygen and nutrient-rich blood to the extremities, and this process is blocked by physiological reasons (5).  

Since we now know how to identify and treat venous ulcers, we are one step closer to understanding the main differences between arterial vs. venous ulcers; let’s keep going! 

Causes (8) 

• Diabetes 

• Inflammation 

• Fat blockages  

• Clogged arteries  

• Peripheral arterial disease (PAD) 

• Infection  

• Blood disorders (sickle cell disease, thalassemia) 

• Bed-bound 

Signs and Symptoms (9) 

• Wounds are usually located distally on the dorsum of the foot or toes 

• Wound bed is typically grayish, and granulation tissue appears unhealthy 

• Little to no bleeding is noted 

• Painful, especially at night when supine-putting leg dependent will relieve pain (opposite of venous ulcers) 

• Pale skin, hairlessness 

• Diminished pulses, cool to touch 

• Intermittent claudication- is a reproducible discomfort of a defined group of muscles (usually lower legs) that is induced by exercise and relieved with rest (9) 

Remember, the extremity is not getting perfusion, which limits oxygen and nutrients!  

Complications

• Infection/gangrene 

• Tissue necrosis 

• Amputation  

Risk Factors(9) 

• Diabetes mellitus 

• Age (risk increases after 40) 

• Arteriosclerosis  

• Vasculitis  

• Foot deformity and callus formation, which causes areas of high-pressure 

• Obesity 

• Peripheral neuropathy 

• Smoking 

• Limited joint mobility/ any trauma to lower extremities  

• Hypertension 

• Hyperlipidemia 

• Family history of atherosclerotic vascular disease 

Treatments

Treatments vary depending on the severity of the arterial disease, but the goal is to increase circulation and correct poor arterial blood supply. Ischemic wounds, unlike venous, are usually kept dry to reduce the risk of infection (5). Treatment focuses on healing and protecting from infection by covering it with dressings or using topical agents.  

• Endovascular therapy, bypass surgery, revascularization, balloon angioplasty 

• Medications that cause blood vessels to dilate 

• Modify contributing factors (smoking, weight, control DM, take meds as prescribed) 

• Boot pumps  

• Hyperbaric oxygen therapy (HBOT)  

• Harmful pressure wound devices (wound vacs)  

• Monitor signs and symptoms of infection, ensuring no tunneling or tracking 

• Amputation- last resort 

• Dry gauze or topical films  

• Larvae therapy  

• Debridement of the ulcer 

Patient Education (5)

• Examine feet (especially between the toes) and legs daily for any unusual color changes or sores development.  

• Manage blood pressure, cholesterol, triglyceride, and glucose levels 

• Quit smoking 

• Avoid cold, caffeine, nicotine, and constrictive garments  

• Walking (most doctors want these patients to walk daily) 

• Take medications as directed  

• Teach the patient the signs and symptoms of wound infection 

• Education on skincare, nutrition, and weight loss 

Neurotrophic (Diabetic) Ulcers 

Pathophysiology

Neuropathic or diabetic ulcers are caused by the loss of protective sensation in combination with structural changes and repeated trauma/pressure to the foot (9). They are frequently found on the toes or metatarsal heads and may be preceded by callus formation (9). Neuropathic or diabetic ulcers may have neuropathic, vascular, and immune system components. Most of these ulcers are the result of a patient being in a hyperglycemic state due to diabetes but can occur in anyone who has impaired sensation in their feet. When patients are in a hyperglycemic state, it produces oxidative stress on nerve cells and leads to neuropathy, which is common in diabetic patients. As the nerve damage continues, it damages the nerve cell protein and leads to further ischemia, resulting in even more impaired wound healing. These cellular changes manifest in 3 ways: 

• Motor nerve damage- leads to an imbalance of flexors and extensors, anatomic deformities, and eventual skin ulcerations. 

• Autonomic nerve damage impairs sweat gland function, leading to reduced moisture and causing epidermal cracks and skin breakdown. 

• Sensory nerve damage- reduced sensation; thus, patients do not feel pain with injury or ulcers (4) 

Neuropathic ulcers arise due to neuropathy, a physiological process that leads to decreased sensory function, motor weakness, and loss of autonomic function. These ulcers often contain calluses, fibrotic tissue, and hyperkeratotic tissues. There are many causes of neuropathy, including diabetes mellitus, central nervous system or peripheral nervous system trauma, alcoholism, along with other disease processes. The most significant factors are the inability of nerves to function correctly, comorbidities leading to neuropathy, and some form of prominence leading to increased trauma or microtrauma to an area (8). 

Statistics indicate that 15-25% of individuals with a diagnosis of diabetes will develop a neuropathic ulcer during their lifetime. In the United States, diabetic-related nonhealing ulcers account for 140,000 amputations per year. The disease burden of neuropathic ulcers affects racial and ethnic minority groups, with Native Americans, African Americans, and Hispanics having increased rates compared to their White counterparts (8). Groups who have increased risk are those who have food insecurities, unsafe neighborhoods, perceived stress, depression, self-efficacy, and discrimination. People living in rural areas and the South are reported to have a lower incidence of amputation than those living in the Northeast. (8) 

Signs and Symptoms (10) 

• Wounds are located at increased pressure points on the plantar surface and surrounded by callus. 

• Depending on the patient’s circulation, the appearance at the wound base is variable and may appear pink/red or brown/ black. 

• Wound borders are punched out, while the surrounding skin is often calloused. 

• Patients may complain of tingling, numbness, or burning 

• Undermining is often present along the wound edges 

Complications

• Osteomyelitis 

• Infections 

• Amputation 

Risk factors (8) 

• Previous lower extremity amputation 

• History of a foot ulcer 

• Anatomic foot deformity 

• Peripheral vascular disease 

• Peripheral nephropathy  

• Diabetes, especially with poor glycemic control 

• Smoking 

• Hypertension 

• Age  

• Peripheral artery disease 

• Anemia  

Treatments (4) 

Treatment and management require a two-fold approach; first, the underlying cause of neuropathy must be treated, and second, the ulceration itself must be treated. After ulceration heals (or before it begins), efforts must be focused on preventative medicine, which includes understanding and changing the biomechanical structures of the foot via orthotic prescriptions and modifications, surgical intervention, and reconstruction of underlying deformities to decrease plantar loading. 

• Avoiding pressure and weight-bearing on the affected leg  

• Regular debridement is necessary to allow healing 

• Autolytic debridement:  lysis of necrotic tissue by the patient’s WBC and enzymes (occurs naturally). Most of the time, this is not enough 

• Chemical debridement: a topical medication prescribed by the provider; examples include Collagense (Sanytl) and Papain with urea (Accuzyme, Gladase) 

• Mechanical debridement: wet to dry dressings (not standard as they are not selective), whirlpool treatments 

• Sharp debridement: sterile scalpel to remove dead tissue 

• Surgical debridement: operating room to remove dead tissue (6) 

• Frequently, special shoes or orthotic devices must be worn 

• Harmful pressure wound devices (wound vacs)  

• Hyperbaric oxygen therapy (HBOT)  

• revascularization 

Patient Education (11)  

Patient education should start with preventative foot education and self-examination. 

• Avoid going barefoot, even at home, especially on hot decks and hot sand 

• Test water temperature before stepping into a bath 

• See a podiatrist regularly 

• Wash feet in lukewarm water, dry thoroughly (including between the toes), and check feet daily for any skin breakdown. 

• Shoes should be snug but not tight and customized if feet are deformed or have ulcers. 

• Change socks daily 

• Avoid smoking 

• Avoid cold, caffeine, nicotine, and constrictive garments  

• Glycemic control  

• Exercise  

• Offloading  

• Infection control  ​

Diagnostic Tests for Ulcers (6) 

Nondiagnostics for Ulcers 

Complete medical and social history: Medical and social history is vital in identifying contributing factors that could influence wound healing. 

Wound Consultant: This is often done to ensure the best treatment is being provided, and wounds are often followed by a wound care center program, ensuring frequent assessments and continual monitoring.  

Nutrition Consultant: adequate nutrition is needed for wound healing, and a registered dietician is often consulted to ensure the proper protein and other nutrients are part of the patient’s care plan.  

Conclusion

Understanding the pathophysiology of venous stasis ulcers, neurotrophic (diabetic), and arterial (ischemic ulcers) along with the circulatory system will assist you in identifying key differences and similarities in these types of wounds. Patients need to understand the “why” in their disease process. Connecting and explaining things in simple, plain language to patients increases their engagement and empowers them to take control of their disease or chronic condition. 

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