Venous insufficiency and ulcers: Clinical sciences

Venous insufficiency occurs when the veins in the legs are not able to effectively return blood to the heart due to defective valves, obstruction, or insufficient muscle pump function. These can cause blood to reflux and pool in the veins, leading to venous congestion, hypertension, and dilation. Venous insufficiency can occur in superficial veins, which include greater and lesser saphenous, and in deep veins, like femoral and popliteal.

Over time, fluid and other substances leak out into the surrounding tissues, causing increased hydrostatic pressure within the capillary bed. This reduces oxygen transport and promotes accumulation of metabolic waste, causing skin changes, and eventually can lead to the development of an ulcer.

Your first step in evaluating a patient presenting with signs and symptoms suggestive of venous insufficiency with or without an ulcer is to obtain a focused history and physical examination. An important thing to keep in mind about venous insufficiency is that abnormal blood flow can increase risk of infection especially if there is a break in the skin that can introduce bacteria into the area. Because of this, you should be on the lookout for any red flag signs of superimposed infection such as fever, rapidly progressive erythema with a possible crepitus, and septic shock.

If you see any of these red flags, obtain a wound culture, start IV broad-spectrum antibiotics, and obtain an emergent surgical evaluation for debridement of the infected ulcer. Timely diagnosis and treatment is very important because these infections can quickly progress into necrotizing soft tissue infection, which can be life-threatening.

Now that we’ve treated the superimposed infection, let’s turn to chronic venous insufficiency and venous insufficiency ulcers without infection. History often reveals lower extremity heaviness , pain, and swelling. Sometimes, patients report pruritus, tingling, and numbness of their lower extremities as well. Some of the risk factors you should look for include a history of deep vein thrombosis, or DVT, an occupation that requires standing for long periods of time, or obesity. These factors tend to impede proper venous return within the lower extremities increasing the risk of developing incompetent venous valves.

When it comes to the physical exam, you can expect to find symptoms of stasis dermatitis due to chronic inflammation. This includes yellow-brown pigmentation of the skin, which occurs as a result of hemosiderin deposits in the skin from stagnant blood within the lower extremity. Patients may also have lipodermatosclerosis, which includes skin changes such as brawny edema and hardening of the skin, so it looks like the bark of a tree due to fibrotic changes under the skin.

You might also see telangiectasias, reticular veins, varicose veins, and spider veins. Lastly, you might see associated ulcers located on the same affected extremity. If you see these findings, you can suspect chronic venous insufficiency.