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Leg Sores


OVERVIEW OF Leg Sores :

Leg ulcers are unhealed sores or open wounds on the legs. Without treatment, these types of ulcers can keep recurring.

The condition is most commonly caused by poor circulation though it may be attributed to a variety of ailments.

These wounds are also more common in women, but they can affect both men and women of any age. If they’re treated early, leg ulcers can improve without causing any further complications.


CAUSES :

Poor blood circulation

Diabetes

Hypertension ( High blood pressure)

Heart disease

High Cholesterol

Kidney disease

Increased pressure in the legs

Smoking

Infections

Varicose veins which are swollen and visible veins are frequently associated with leg ulcers. Often leg ulcers are a complication od untreated varicose veins.


PATHOPHYSIOLOGY :

The exact cause of venous ulcers is not certain but the main mechanism is the venous stasis which is caused by chronic venous insufficiency or congestive heart failure. Venous stasis causes the pressure in veins to increase. The body needs the pressure gradient between the arteries and veins in order for the heart to pump blood forward through arteries and veins. When the venous hypertension exists, arteries no longer shows the high pressure than veins and the blood is not pumped into and out of the area. Increase in the pressure in the veins may also stretch veins and allow blood proteins to leak into the extravascular space isolating extracellular matrix molecules and growth factors preventing them from helping to heal the wound. Leakage of fibrinogen from veins as  well as deficiencies in fibrinolysis may also causes the fibrin to build up around the vessels preventing oxygen and nutrients from reaching the cells. Inadequate in the function of the veins results in accumulation of the white blood in the smll blood vessels releasing inflammatory factors and reactive oxygen species such as the release of the free radicals and further results in the chronic wound formation. Buildup of white blood cells in small blood vessels may also lead to the plugging of the vessels, further resulting in the ischaemia. This blockage of blood vessels by leukocytes is responsible for the no reflow phenomenon in which the ischemic tissue is never fully reperfused. Allowing the blood to flow back into the limb by elevating is necessary but also contribute to the reperfusion injury. The venous stasis occurs. It results from damage to the veins in the valvular system in the lower extremity and in extreme cases it allows the pressure in the veins to reach higher than the pressure in the arteries. This pressure results in transduation of inflammatory meditors into the subcutaneous tissues of the lower extremity and subsequent breakdowm of the tissue including the skin.

Wounds of the distal lower extremities arising from causes not directly related to venous insufficiency (e.g., scratch, bite, burn, or surgical incision) may ultimately fail to heal if underlying (often undiagnosed) venous disease is not properly addressed


COMMON CLINICAL SIGNS AND SYMPTOMS :

The symptoms of leg ulcers can vary depending on the exact cause. Ulcers are often painful. But sometimes ulcers present with no pain. This is due to nerve damage from unmanaged diabetes. A lack of pain results the persons asymptomatic.

Open sores

Pus in the affected area

Pain in the affected area

Increase wound size

Leg swelling

Enlarged veins

Generalized pain or heaviness in the legs.


DIAGNOSTIC :

Imaging studies:

Angiography:

It can visualize the vessesls of the lower extremities . a femoral analysis is the study o choice.

Magnetic resonance angiography:

It helps to visualize the vessels of the lower extremities disease.

Doppler scanning:

It can detects the venous reflex with greater sensitivity. Ascending venography also may be considered to obtain detailed anatomic information.

Ankle brachial indices (ABIs):

The ankle brachial indices and toe digital pressures with pulse volume recordings can provide the perfusion of the foot.

Xenon 133 clearance to measure blood flow can help to estimate the chance of wound healing.

Transcutaneous oxygen tension may be measured. The pressure of 30-35 mm Hg is sufficient for healing of more than 90% of wounds.


TREATMENT AND PROGNOSIS :

The main aim of the treatment is provide the keen areas which favours the growth of the skin in an ulcer area. In majority of cases this requires finding and treating underlying venous reflux. Most venous ulcers respond to patient education, elevation of the foot, elastic compression and evaluation which is known as Bisgaard regimen. Exercises along with compression stocking increases the process of healing. There is no evidence that antibiotics whether administered intravenously or by the mouth are very much useful. Silver products are also not useful.

Compression therapy:

Non elastic, below knee compression counters the impact of reflux on venous pump failure.

Compression therapy restricts the back flow of the blood. It is also useful to decrease the release of inflammatory cytokines, lower the amount of the fluid leaking from capillaries and therefore prevent swelling and also prevents the clotting by decreasing the activation of thrombin and increasing that of plasmin. Compression is applied using the elastic bandages or boots which are specifically designed for this purpose.

Medications:

Pentoxifylline is useful in the treatment of the compression stockings . it reduces the platelet aggregation and reduces the thrombus formation. Sulodexide also reduces the formation of the blood clots and reduces the inflammation and promotes the healing of the venous ulcers.

Aspirin can also be used which provides the better relief.

Wound cleaning solutions:

Wound cleansing solutions such as polyhexamathylene biguanide, aqueous oxygen peroxide are better than sterile water or saline solutions in the healing of the venous ulcer.

Skin grafts and artificial skin:

Skin grafts which are made artificially from the collagen and cultures skin cells is also used to heal the venous ulcer.

Surgery:

Thermo ablation , laser ablation and radiofrequency,  perforator closure and foam sclerotherapy is useful in the  healing the ulcer.

Dressings:

Silver containing dressing increases the chances for healing the ulcers.


PROGNOSIS :

Venous ulcers are costly to treat, and there is a significant chance that they will recur after healing. One study found that up to 48% of venous ulcers had recurred by the fifth year after healing. However treatment with local anaesthetic endovenous techniques suggests a reduction of this high recurrence rate is possible.

Without proper care, the ulcer may get infected leading to cellulitis or gangrene and eventually may need amputation of the part of limb in future.

Some topical drugs used to treat venous ulcer may cause venous eczema.


PREVENTION :

Getting help with the compression socking

Losing the weight

Maintain the healthy diet and lifestyle

If longstanding ulcers are found seek the medical help as soon as possible.