Treatment of leg ulcers
Leg ulcers with brown haemosiderin and zinc cream
As stated on the previous pages, it is the aim of a vein specialist and a specialist vein clinic to identify which leg ulcers are venous, and which of the venous ulcers are due to superficial venous reflux disease (“hidden varicose veins“).
When a patient attends a specialist vein clinic with a leg ulcer, a full history of the events leading up to leg ulceration will be taken and the leg will be examined by a specialist using a duplex ultrasound. The superficial and deep veins will be examined, checking that all of the veins are open and making sure there is no venous reflux suggesting that the valves are not working in any particular vein. The arteries will then be checked once again using a duplex ultrasound. In addition, other tests such as photoplethysmography (PPG) may be used to test the venous function and arterial pressure can be checked with a Doppler (ABPI – “ankle brachial pressure index”).
Once it has been decided that a leg ulcer is due to superficial venous reflux (“hidden varicose veins“), a venous expert will be able to decide which of the new local anaesthetic, minimally invasive techniques will be required to cure the venous reflux and hence cure the leg ulcer. As with varicose veins, the treatments are likely to be a combination of:
There may occasionally be the need for other treatments such as coil embolisation of pelvic veins or one of the new techniques such as ClariVein, steam vein sclerosis (SVS) or glue sclerotherapy, but these techniques require further evaluation for these indications at the present time.
In venous occlusive disease, treatment of an acute deep vein thrombosis is by warfarin (or other anticoagulants – a substance that prevents clotting of the blood) and in the majority of cases this completely clears away the deep vein thrombosis (DVT) without any damage to the deep veins or valves of the deep veins. Treatment of venous occlusive disease in the deep veins is much more difficult if the condition has damaged the deep veins and the venous valves resulting in a “post phlebitic limb” or leg ulceration.
In such cases, most patients are consigned to regular dressings of the leg ulcer and tight bandaging of the leg. This can result in a short term cure but as the underlying condition is not being treated, the leg ulcers will always recur when the compression bandaging is removed. Very specialist units do treat these leg ulcers using powerful “clot busting drugs” called thrombolytic agents (a process called thrombolysis) and then little metal tubes called “stents” are inserted to hold the vein open once the clot has been cleared. There is a reasonable amount of success in such cases, provided the patient is very active and mobile to keep the venous pump working optimally.
As far as repairing the deep veins and their valves, despite many years of research, there is still no very successful way of repairing or replacing valves in the deep veins.
Arterial leg ulcers and leg ulcers due to other conditions:
A venous specialist in a specialist vein clinic will be able to identify ulcers that are not due to venous disease and will be able to make appropriate referrals to other specialists who can deal with the problem that has been identified as the cause of the leg ulcer.
What you should do if you have a leg ulcer:
If you develop a leg ulcer, you should attend your local family doctor or go direct to a specialist vein clinic, whatever is usual practice in your country or local area.
You should not accept a referral to a “ulcer clinic” which only provides dressing and bandaging as “treatment” and which only assesses the arterial Doppler pressure at the ankle and arm (ABPI) when “investigating” the ulcer. If there is not the minimum of a full venous duplex ultrasound scan, with a venous specialist who can perform endovenous laser ablation (EVLA), radiofrequency ablation (RFA) and foam sclerotherapy (UGFS) to treat the underlying cause, then you are not even been given an opportunity to find out whether your leg ulcer is curable.
Unfortunately, as the “traditional” way of managing leg ulcers is by dressing and compression bandaging (or stockings) alone. You may have to insist on referral to a specialist vein clinic or refer yourself, if you are to find out whether your leg ulcer is curable. What you should always remember is that if you are mobile and able to walk by yourself, then there is a high chance that your leg ulcer is curable by a true vein specialist.