Health Matters: Development of leg ulcers a slow process

Our protagonist, Tom, was a good-natured fellow, a traffic cop for many years. He loved working with the kids, playing the conductor, but hated the prolonged periods of “just standing there.” Early on, he could do his job without difficulty, suffering only occasionally from boredom. Over time, this changed, and he noticed his legs ached towards the end of the workday. He thought little of it, just a hazard of the job, until the swelling developed.

By the end of his average day, both ankles would be swollen and aching, relieved only by planting himself on his recliner and cranking up the footrest. His wife wasn’t happy about his inclination to elevate his legs rather than helping around the house, but it was his greatest means of relief. And the swelling (and pain) wasn’t getting any better, instead, only worsening with time. Still, the pain never became disabling, and he was able to ignore it.

The appearance of a darkened area on his shins was disconcerting but without symptoms. The skin in this area also was stiffening slightly, imperceptibly, over the years. Tom was one of those guys who hated going to the doctor and did so reluctantly, revealing as little as possible. The subject of his legs never came up during his yearly visit to his primary care provider, so the issue was never addressed. (Funny how that works: if your physician doesn’t know about the problem, then they can’t tell you something is wrong!)

Tom was experiencing a common condition, not a rarity that is seen only in the medical journals. Estimates state nearly one in 20 Americans has some changes associated with CVI, Chronic Venous Insufficiency. Defined as the abnormal flow of blood inside the veins of the lower leg, whereby blood is being pulled by gravity back down towards the feet. Normally, valves inside our veins keep this from happening, but when they malfunction, these vital fluids pool in calf veins.

With CVI, an iron-containing substance can get deposited in the skin, causing a brownish discoloration. Over time, this material, hemosiderin, builds up and poisons the epidermis (the outer skin layer) in the lower calf region. Even the slightest trauma (or sometimes no) can produce an open, draining sore that won’t heal, technically referred to as a venous stasis ulcer.

Tom bumped his shin on a broom handle and developed one of these sores. It didn’t look all that bad at first and wasn’t anything more than tender. He paid it no mind, although he had to keep it covered since it was leaking. Eventually, the wife could stand it no longer (the smell!) and made an appointment at their primary care office. An antibiotic was prescribed (although it didn’t feel like it was infected….) and an ointment dispensed.

The ulcer had enlarged over time and the watery liquid produced required frequent dressing changes. Despite the addition of a home visit nurse to help with the dressings, he saw no improvement in the size or appearance of the wound. And so it went, relatively unchanging for months. Not healing, just draining, tender, and sore.

A physician specializing in wound care understands the benefits of identifying the root of the problem. What condition is preventing the proper healing process from progressing? Without this vital information, the rate of closure is reduced, meaning fewer of these chronic wounds are healed. Tom’s ulcer was clearly due to CVI, the vein condition plaguing him most of his adult life. For Tom’s wound to heal, the backflow of blood had to be treated.

A specialized, multi-layer, medicated wrap was applied, not to the area of the wound, but to the entire lower leg, ankle, and foot. This increases the flow of blood back up to the heart, the way it’s supposed to go, up the lower leg. This aids in the healing process of the ulcer, and the skin in general. In Tom’s case, healing didn’t progress quickly enough, and a cellular tissue product was used (in this case, a fake skin grown in a lab). When the cause is addressed, many of these long-standing, chronic ulcers can be healed, as was Tom’s. Compression is the mainstay of therapy for many of these vein diseases. A difficult question is what type of compression, with numerous methods available, some “old school” and others hi tech. By far the most commonly prescribed method of treating the condition before there is breakdown of the skin are compression stockings. These thick, heavy stockings that go over the foot, ankle, and lower leg are made of an elasticized material which results in compression of the limb. Unfortunately, if these garments are tight enough to be effective, they are too tight for most seniors to don. If the patient is successful (usually only with assistance), the garment is not comfortable to keep on.

Powered pneumatic systems (think of giant socks that inflate) are available and some of them are quite effective, but if they work well, they are costly. The most exciting development in the world of venous insufficiency therapies is a new compression device, basically a sleeve for the lower leg. Velcro tabs allow the patient to control the amount of pressure on the leg. They are significantly more comfortable than prescription compression stockings and are more effective at healing the skin and reducing the swelling.

The ulcerations of venous insufficiency are the result of a long chain of events, starting with the development of incompetent valves. This process can take years to occur, which means interceding in the process is possible. The application of compression therapy of some type, used consistently, will prevent most if not all of the complications of this chronic condition.

Our healthcare system needs to better identify these individuals and prescribe some form of compression. This is a perfect example of what preventative medicine can do. Although not everyone who has some swelling of the leg will progress to a chronic ulcer, with sufficient signs and symptoms, some form of compressive therapy needs to be utilized. An appropriate cliche comes to mind: an ounce of prevention is worth a pound of cure.

EDITORS NOTE Dr. Conway McLean is :a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.


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