What Are Vascular Ulcers?

Vascular ulcers arise when there is a problem within the circulatory (the system that carries blood) system.¹ They can be a significant healthcare concern, especially amongst the elderly as they might be more prone to developing vascular ulcers. Recovery, which takes over 2 weeks commonly with specialised care, may face complications in old age.^1,3 Understanding the mechanism and development of vascular ulcers can help you to effectively support the management and treatment of this condition. In this article, we will explore their causes, clinical presentations (what they can look like), management and treatment approaches.

A vascular ulcer is an open wound/sore found more commonly on the lower extremities of the body (legs). Vascular ulcers can be venous or arterial ulcers and are commonly caused by damaged blood circulation.^1,4 An insufficient supply of blood to the affected area can result in the inability to receive the necessary nutrients and oxygen, leading to local tissue breakdown and ulceration.^1,4

In this article, we will explore the distinction between Venous and Arterial ulcerations, their diagnostic criteria, and the latest advancements in treatment modalities. By gaining an understanding of this condition along with its underlying cause, you can support yourself or those you care for following the right management and treatment of these ulcers to improve quality of life.^1,4

Understanding vascular ulcers

Factors contributing to the development of vascular ulcers

Vascular ulcers have two general causes - one is due to poor circulation in the veins, also known as stasis ulcers (stasis meaning stationary).^1,4 This is when the flow of deoxygenated blood and waste products carried from the body towards the heart by veins is slower than normal.^1,4 Venous ulcers can also occur after a minor injury to the leg, which has poor circulation.^1,4 The increased pressure inside the veins damages small blood vessels in the skin, making them fragile. This can cause the veins underneath your skin to break easily from any minor injury to that area, causing the formation of an ulcer.^1,5

The other less common cause of vascular ulcers is poor circulation in the arteries, where oxygenated blood and nutrients are carried away from the heart towards other parts of the body.⁵ Poor circulation can thus have a starving effect on the areas of the body where that artery may be supplying, causing the formation of a vascular arterial ulcer.^1,5

Vascular ulcers most often have multifactorial causes, an example being obesity. Some common predisposing factors that may cause vascular ulcers have been discussed below: 

Peripheral artery disease (PAD)

Peripheral artery disease is the accumulation of plaque (hardened deposits of fat and cholesterol) in the arteries of the legs. The hardening of the arteries because of plaque formation is also known as atherosclerosis.⁶ This buildup narrows the walls of the arteries, increasing blood pressure, thus not allowing sufficient oxygen and nutrients to reach the living leg muscles and cells.⁶ If the hardened outer layer of the plaque can break off and cause the formation of clots inside the blood vessels, this can obstruct the arteries and further cut off the essential supply.^1,6 This can cause skin and soft tissue ulcerations and infections due to hypertension of the peripheral vessels.^1,6  

Venous insufficiency 

Valves prevent the backflow of blood in veins.^1,6 Venous insufficiency might occur when these valves are impaired in the veins in your leg. This may make it harder to move blood back into the heart for re-oxygenation.^1-6 This causes blood to pool at the bottom of the legs, causing an increase in the blood pressure within the veins and extreme swelling.^1,3,5 This increase blood pressure over a long period of time can damage the walls of the veins, thus lead to the formation of ulcers following any minor injury.^1,6 

Diabetic neuropathy

Diabetic patients often suffer from long-term comorbidities as constant high blood glucose levels is harmful to blood vessels and nerves.^1,6 Damage to the nerves can cause neuropathy, leading to numbness, tingling, pain and loss of sensation in the legs.^1,6 Neuropathy can increase an individual's risk of being prone to trauma. Trauma coupled with delayed wound healing in diabetics makes for a harmful combination that can cause diabetic foot ulcers.⁷ Diabetic foot ulcers are generally regarded as a separate category of foot ulcers that may primarily require diabetic treatment before/along with vascular care for their ulcers.⁷ 

Prevalence and demographic factors 

In the UK, venous leg ulcers are thought to affect 1 in 500 individuals, though they become much more prevalent with age. As obesity rates increase, the rate of vascular ulcers observes an increase due to the complications and comorbidities associated with diabetes.^1,7

Types of vascular ulcers

Vascular ulcers are classified based on the underlying cause of the ulcer. However, the underlying cause might be difficult to diagnose through clinical examination only. Hence, the common physical characteristics of vascular ulcers are useful in identifying different types of vascular ulcers. 

Arterial ulcers 

Arterial ulcers have a more distinct and regular border, often presenting a “gouged-out” appearance.2 The base of the ulcer also contains greyish tissue, and there may be redness surrounding the ulcer.2 These ulcers may often be painful, and the skin around the ulcer may feel cool to touch.^1,7 There can be signs of ischemia, which is insufficient blood supply.^1,7 Ischemia can present as pale skin, hairlessness, and an absent pulse.^1,7 

Venous ulcers

Venous or stasis ulcers can be larger, though shallower than arterial ulcers. However, if they are left untreated, they can grow deeper until they are completely penetrating the skin down to the bone.^1,2 They usually have an irregular border, and the skin surrounding the ulcer exhibits stasis dermatitis. Stasis dermatitis is a type of eczema resulting from the pooling of venous blood, leading to discolouration. The majority of venous ulcers are exudative, releasing pus, which can be foul-smelling.^1,7

Etiology and pathophysiology

Underlying causes of vascular ulcers 

Atherosclerosis 

Hypertension and atherosclerosis of the peripheral vessels are usually a major cause of the onset of arterial ulcers.⁶ The buildup of plaque on the arterial walls narrows the vessel, increasing its pressure and preventing sufficient blood supply to tissues, causing ulcers.^1,7 Arterial or ischemic ulcers also occur due to atherosclerosis or arterial embolization - a blood clot that blocks the artery, leading to ischemia of the skin and ulceration.⁶ 

Valvular dysfunction

Valves are naturally existing mechanisms inside veins that prevent blood from flowing backwards or pooling at the bottom of the feet.^1,7 When veins in the legs cannot pump blood to the heart, swelling occurs in the legs as these veins experience an increase in pressure and cause varicose veins. Over time, the sustained increase in blood pressure damages the walls of the veins and can make them fragile and prone to ulcers.^1,7 

Deep venous thrombosis

Venous ulcers are usually caused by hypertension as a result of valvular incompetence, which can have no underlying cause or can be due to deep venous thrombosis.⁸ Deep venous thrombosis is when blood clots block the vein, narrowing the vessel and not allowing valves and the vessel walls to function adequately.⁸

Clinical presentation and diagnosis

Signs and symptoms

Some common signs and symptoms seen in arterial ulcers are (DermNet): 

• Sores are commonly located on the lower legs or tops of the toes
• Symmetrically shaped with borders that are well-defined, giving the ulcer a punched-out appearance.
• Discolouration or reddening of the skin around the ulcer
• Swollen ankles
• Itching 
• Increasing pain during the night times
• Loss of hair on the affected leg
• Cool, bluish and pale skin surrounding the ulcer
• Absent of faint pulse in the legs

Some common signs and symptoms of venous ulcers are (NHS): 

• Swelling in your ankles (oedema)
• Darkening or discolouration of the skin surrounding the ulcer
• Hardened skin around the sore, which may make the leg feel hard
• A heavy feeling in the affected leg
• Swelling or aching in your legs
• Flaky, scaly and itchy skin on your legs (varicose eczema)
• Swollen and enlarged veins on your legs (varicose veins)
• Worsening pain
• An unpleasant or green discharge from the ulcer – redness may be harder to see on black or brown skin.
• Swelling and redness of the skin around the sore
• A high temperature (fever)
• An unpleasant smell 

Diagnostic tools and techniques 

Primary diagnosis is largely based on examining the ulcer. However, further tests may be ordered. Doctors will take a complete medical and surgical history, asking questions related to diabetes, deep vein thrombosis, and any injuries that could be the underlying cause of the leg ulcer.²

Doppler tests are commonly carried out to aid in the diagnosis of vascular ulcers.⁹ This involves comparing the blood pressure in the arteries of your ankles to the blood pressure in your arms to determine the ankle-brachial pressure index (ABPI) to exclude arterial insufficiency. If you have PAD, then the blood pressure in your ankles will be lower than in your arms. This is an important distinction as the treatment plan for leg ulcers is compression bandages to improve circulation. It is unsafe to apply compression if the artery pressure in your ankles is low.1-9 Similarly, doppler ultrasonography may also help aid the diagnosis of venous ulcers.⁹  

Complications and impact

Potential complications arising from untreated vascular ulcers

The potential risks of leaving leg ulcers untreated are:

1. Infection - The most common complication for venous ulcers. This can be in the form of bacterial, viral, fungal or protozoal. This can lead to a fever, discharge of pus, necrotic tissue, and significant pain.^1,9
2. Venous eczema- This usually occurs before an infection and can range in severity based on your overall health. Mild cases can present itchiness, redness, and some swelling but can develop into discolouration and scarring in severe cases, leading to infections if left untreated.^1,9 
3. Psychological issues- Although leg ulcers may not seem like a psychological concern, it is possible if left untreated, they can lead to significant mental health concerns.^1,9 Patients restrict their movement due to the pain and are left indoors and isolated and vulnerable to mental health disorders.^1,9  

Treatment approaches

Some common treatment approaches for treating vascular ulcers are:

Wound care and dressings

With the right treatment plan, leg ulcers can heal within 6 months. Treatment should always be carried out under the supervision of a healthcare professional.

Firstly, it is important to remove any debris from the ulcer wash and dry the wound to allow the optimal conditions for healing. A simple wound dressing will be applied, which will be changed 1-3 times a week. This can be done by the patient themselves or by their carer, under appropriate supervision.^1,9 

Compression therapy

To improve venous circulation and stop the pooling of blood at the bottom of the feet, a compression bandage that squeezes the legs and stimulates blood flow can be worn.^1,9 This bandage is applied over the dressing and is changed 1,3 times a week. Keeping your leg elevated when possible also helps ease the swelling.^1,9

Medications

When compression bandages are first applied, it is usually painful as the ulcer has not started healing. The pain should ideally decrease over time, however non-steroidal anti-inflammatory drugs such as paracetamol can be used to manage the pain. If you are experiencing itchiness, usually caused by venous eczema, your doctor may prescribe you a mild corticosteroid cream and a moisturiser to treat dry skin. If the ulcer is infected, then you can be prescribed a 7-day course of antibiotics if needed. (NHS)

Individual treatment approaches will need to be tailored as per the patient’s condition and the ulcer, thus we recommend discussing your clinical plan of treatment with your treating clinician.

Prevention and lifestyle management

Continuing to wear compression stockings, losing weight to decrease pressure in your legs(through regular exercise and a balanced, healthy diet), and elevating your legs whenever possible are some of the ways you can prevent the recurrence or risk of developing venous ulcers.^1,9

Summary

In this article, we explored venous and arterial ulcers. In the UK, venous leg ulcers are thought to affect 1 in 500 individuals, though they become much more prevalent as people age. These chronic leg sores require specialised care. They can result from poor circulation in the veins (venous ulcers) or arteries (arterial ulcers) due to individual or multifactorial causes such as hypertension, atherosclerosis and/or venous insufficiency. Diagnosis involves clinical evaluation and tests like Doppler ultrasound, with treatment options ranging from wound care and compression therapy to medications. Untreated ulcers can lead to complications, including infections and psychological distress. Preventive measures, such as weight management and lifestyle changes, are crucial for reducing the risk of occurrence or recurrence.