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A better understanding of the causes of Leg Ulcers has helped establish Leg Ulcer treatment, which can permanently cure a long term problem.
The two major causes of all Leg Ulcers are venous (veins not working, which accounts for about 80% of Leg Ulcers) and arterial (arteries not working, which accounts for about 15% of Leg Ulcers). However, there are rarer causes and considerations for diabetic and malignant Leg Ulcers, which are also outlined below.
We will focus on venous Leg Ulcers as they are the most common and, with specialist treatment, often the easiest to cure. A good vascular surgeon will nonetheless check for arterial and other causes before commencing treatment. Patients may have more than one cause of Leg Ulcers, and even though a venous origin may be found, there could also be arterial or other issues present at the same time.
Fortunately, most arterial Leg Ulcers can be cured by bypass surgery or angioplasty. So by accurately identifying the cause (or causes), the appropriate treatment protocol can be formulated, often utilizing a combined approach of treating the arterial issues first, followed by the venous cause.
The remaining 5% of diabetic and malignant Leg Ulcers may equally be open to treatment.
Most Leg Ulcers are venous in origin and can be caused by:
As there are a number of different underlying venous causes for Leg Ulcers, so there can also be a wide variety of symptoms.
Leg Ulcers can, at times, be painful. This is often due to infection on top of the Leg Ulcer, or to the physical irritation and chafing of dressings, bandaging or compression bindings.
The severity of venous disease of the legs which is severe enough to cause Leg Ulcers can also cause swelling of the lower legs. This swelling can itself cause symptoms, with the skin feeling tight and the leg feeling heavy or full. Often there is itching of the skin, or tension in the skin due to the inflammation and swelling.
However, venous Leg Ulcers can also sometimes be asymptomatic, causing no pain or discomfort, although there will still be an open break in the skin requiring dressings.
Classically, venous Leg Ulcers improve and any associated pain reduces when the patient is lying down and the leg is elevated, as gravity works with the body to drain the venous blood out of the leg. Conversely, as the leg is below the level of the heart, when the patient is sitting or standing, the venous Leg Ulcers worsen.
Arterial Leg Ulcers occur when there is not enough pressure in the arterial blood to force it through the capillaries in the toes, feet or lower ankles. If arterial blood does not go through these capillaries, then the vital supplies of oxygen and food such as glucose do not get to the tissues.
In addition, waste products from the tissues, such as carbon dioxide, urea and water, are not removed and therefore remain in the tissues. The combination of lack of oxygen and food and the accumulation of waste products damages the tissues and causes many cells to die. This tissue damage is almost always painful, making that a key symptom of arterial Leg Ulcers.
Contrary to the case with venous Leg Ulcers, the pain from arterial Leg Ulcers is usually improved when the legs are below the heart, particularly when the patient is sitting or standing. This is because gravity helps the flow of blood from the heart to get to the capillaries in the ankle, feet and toes. Conversely, the pain of arterial Leg Ulcers is made worse when the leg is elevated, for instance when the patient is lying down, as gravity is working against the flow of blood to the tissues in the lower leg, or foot and is worsening the condition. Consequently, many people with arterial Leg Ulcers often get out of bed at night, hang their leg out of the bed, or walk around, perhaps to sit in a chair.
Although many doctors and nurses refer to ‘diabetic Leg Ulcers’, these are almost always arterial Leg Ulcers that just happen to be occurring in a patient with diabetes.
In diabetes, the small capillaries may be damaged as well as the major blood vessels (arteries), so ulceration is more common and often more severe. Even more importantly, one of the problems with diabetes can be a loss of sensation in the toes, feet and lower legs. When this happens, what would ordinarily be a very painful arterial Leg Ulcer becomes asymptomatic and diabetic patients may not even realise that they have this additional condition. As a result, they often do not seek medical care or treatment until the ulcer has become severe, or grossly infected.
For this reason, The Whiteley Clinic strongly recommends that anyone with diabetes and any breakdown of the skin should consult a specialist doctor or nurse as soon as possible.
One other rare but important type is the malignant Leg Ulcer. Quite often, this is actually a venous Leg Ulcer that has not been cured and has simply left open for a great many years. They are often referred to as a “Marjolin’s Ulcer”.
A Marjolin’s Leg Ulcer usually shares the same symptoms as any other underlying venous Leg Ulcer, and can therefore often be ‘asymptomatic’, hence the reason patients either do not seek advice, or why they might only have only been offered the traditional dressings and not a cure. The fact the Leg Ulcer has not been treated for so long is probably the reason it has become malignant.
In all the above cases, an appointment at The Whiteley Clinic is the first step in achieving a long-term cure for Leg Ulcers and swapping the pain of the condition and the inconvenience of traditional NHS dressings and bindings for pain-free, ulcer-free quality of life!