Venous insufficiency is the most common cause of leg ulcers. Atherosclerosis affects the arteries with limited blood flow through them.
Venous Insufficiency-Related Leg Ulcers
Venous insufficiency rises with age, obesity, gender (F > M), pregnancy, prolonged standing (gravity), and a history of deep vein thrombosis (DVT).
Clinical examination is sufficient to make the diagnosis. Spider veins (telangectasias) of the feet and ankles, edema, varicose veins, and brown discoloration (hemosiderin deposits) are common findings. Location is typically from mid-calf to ankle. There is hemosiderin deposition in macrophages that darken the surrounding skin. Stasis dermatitis is inflammatory changes due to venous backup. Edema is common.
Diagnosis is confirmed via ultrasound.
Arterial Disease-Related Leg Ulcers
These are caused by cigarette smoking, diabetes, abnormal lipids, and arterial obstructions. They typically occur at distal points, such as the toes, and at pressure sites overlying bony prominences. There is usually hair loss and the atrophic skin takes on a shiny appearance.
Diagnosis is confirmed via CT angiography and/or MRI angiography.
These present as “punched-out” ulcers over pressure points on the foot or heel most commonly. There is usually callus formation around them. Reduction of sweating (hypo- or anhydrosis) can cause the feet to be dry and scaly.
The diagnosis of ulceration in the legs must include consideration for its cause so that both the ulcer and the tendency to progress can be addressed. As such, tests for the following are indicated:
- Diabetes testing: Including screening tests (2 hour glucose tolerance test after a 75 g glucose load orally)
- For established diabetics: Monthly measures of the glycated hemoglobin A1C
- Evaluation of the blood supply to the lower extremities to rule out arterial vascular disease or chronic venous disease: arteriography imaging, ultrasound
- Evaluation of the peripheral nervous system: For sensory perception as well as chronic vasoconstriction influences from the autonomic nervous system
- Testing for the causes of hypertension, cardiovascular disease, and atherosclerosis: Including lipid panels to identify dyslipidemia (abnromal cholesterol and triglycerides)