WHAT IS IT?A leg ulcer, or "ulcus cruris," is an open sore or ulcer on the lower leg. The normal skin in such a location has disappeared, leaving a usually irregularly bordered open area, often covered with a yellowish-brown coating or crust. The base may also initially be black (dead skin). During treatment, the color returns to its normal red. Healthy skin grows back from the edges and sometimes from the base as well. Before the open sore develops, there are usually long-term abnormalities in the surrounding area, such as fluid retention around the ankles (edema), varicose veins, and brown discoloration.HOW DOES IT COME ABOUT?The cause of a leg ulcer is usually a circulatory disorder. The heart pumps blood to the body's tissues via arteries. This blood carries the oxygen and nutrients necessary for tissue growth and function. The arteries branch into increasingly smaller blood vessels. The smallest are called capillaries. These capillaries extract oxygen and nutrients from the blood and absorb them into the tissues. The capillaries then combine to form veins, and the blood, now depleted of oxygen and nutrients, is returned to the heart.
A leg ulcer can be caused by a disorder in the afferent, arterial system or by an abnormality in the venous system.
In the former case, there is narrowing of the arteries, so that insufficient oxygen and nutrients reach the tissues, causing them to die. This leads to very painful sores that are generally difficult to heal. These sores are most often found on the feet and toes.
The most common cause of a leg ulcer is an abnormality in the venous system, a drainage disorder. In this case, the blood is not properly drained, leading to blood pooling (congestion). When standing, the blood must be pumped upward in the veins against gravity. This is primarily accomplished by the calf muscles. Walking is therefore excellent, but standing or sitting for long periods is detrimental to venous blood flow.
The veins contain valves that prevent blood from flowing back to the feet when standing upright. If these valves no longer close properly, blood easily flows backward, increasing the pressure in the veins and capillaries. This stagnation in blood circulation compromises the nourishment of the tissues. The skin becomes more fragile, and a leg ulcer easily develops.
The described abnormalities in the venous system are usually permanent (chronic). Once the valves are damaged, they cannot be repaired. The malfunctioning of the valves in the venous system is called insufficiency. This brochure focuses primarily on these disorders of the blood vessels that drain blood.WHAT ARE THE PHENOMENA?A tired, heavy feeling in the legs is often the first sign of a vascular drainage disorder. Over the course of the day, the ankles swell due to fluid retention (edema). Over time, dilated veins and varicose veins become visible. Brown discoloration and eczema patches may develop. Subcutaneous hardening can also occur. Eventually, an ulcer develops: an open leg ulcer. The ulcer is usually not painful, but can be foul-smelling and produce a lot of fluid, making it difficult to move around freely. The open sores are usually located around or above the ankles. A previous blockage of the veins (thrombosis) is the main cause of the valves no longer closing properly.
A history of thrombosis may not always be noticeable, as some venous thromboses are symptom-free.WHAT IS THE BEST TREATMENT?The most important part of treating an open leg is to promote blood flow from the leg to the heart. This improves the nutrition in the lower leg and closes the open wound. This can be achieved by applying special pressure bandages.
This treatment is usually performed on an outpatient basis, administered by both the general practitioner and the dermatologist. The bandage should exert firm pressure on the leg and is applied from the forefoot to the knee. The pressure is greatest around the ankle and gradually decreases towards the knee. This prevents blood from flowing back and pumps blood upward during calf muscle movements. Therefore, the bandage is only effective when the calf muscles are being used, so walking is essential. The bandage material is usually not very stretchy, as this, combined with the natural calf muscle pump, has a positive effect on blood circulation. Elastic material can also be used, but often needs to be removed at night because it can become constricting in a horizontal position. This is in contrast to low-stretch bandages that can remain in place for up to several weeks. The total duration of bandaging treatment varies from several weeks to many months. With proper bandaging technique, the risks are very low. Prolonged rest with the leg on a chair or in bed, as was done in the past, is unwise because the calf muscles are not being used. Moreover, muscles and joints become stiff, and the risk of (re)thrombosis increases. If the pain is severe, a short rest period may be advisable.
The final step in the treatment of an open leg caused by a drainage disorder is wearing an elastic stocking. The goal is to prevent new open sores. The stockings must be worn continuously. The elastic wears out, so the pressure becomes insufficient over time. The leg then swells, and a new open sore can develop. Therefore, stockings must be replaced regularly.
Hospitalization is only necessary in exceptional cases. This is the case, for example, if the open leg has not healed after several months of treatment.PAINFor pain, you can take 500 mg of paracetamol, up to a maximum of 6 tablets per day. This painkiller is available without a prescription. Paracetamol is very inexpensive at some large drugstore chains.WHAT CAN YOU STILL DO?Exercise frequently (walking, cycling, swimming) and wear elastic stockings (even in warm weather). This is the most important rule of thumb. Stockings are often most needed on warm days. Avoid being overweight. Avoid constricting clothing such as tight pants, elastic bands, etc. Wear comfortable footwear. High heels prevent the calf muscles from pumping effectively. Elevate your legs when sitting for long periods. If necessary, the foot of the bed can also be raised slightly, provided this doesn't cause shortness of breath.
All these measures will certainly help prevent fluid retention and the heavy, tired feeling in your legs. Nevertheless, it remains possible for a leg ulcer to recur in the future. The underlying cause—the valves and veins not closing properly—is sometimes irreversible.SOME MORE COMMENTSThe doctor will discuss the wound treatment and bandaging method with you and the nurse. You will also be explained the need for a pressure bandage.
Once your wound has been treated and your leg bandaged, the nurse will plan your further care with you.
Wound care and bandage changes usually take place once a week.
The nurse will make the necessary arrangements with you and will try to support you throughout the entire treatment period. If you have any problems, you can always consult the doctor.
If you have difficulty coming to the outpatient clinic once a week, you can contact Home Care (district nursing). You can discuss this with the nurse at the outpatient clinic.
If you experience significant pain between visits or have any questions, please contact the outpatient clinic. |
