Leg Ulcer

Ulcus cruris: description

Ulcus cruris (“open leg”) refers to deep and poorly healing wounds on the lower leg. The term Ulcus cruris comes from the Latin and means in German Unterschenkelgeschwür (Ulcus = ulcer, cruris = lower leg). In common usage, a leg ulcer is often referred to as an open leg. Ulcus cruris is the result of a circulatory disorder in the legs. Physicians distinguish different forms:

Ulcus cruris venosum

In most cases, circulatory disorders are associated with impairments in the venous circulatory system. This condition is called chronic venous insufficiency. Physicians speak in this form of the open leg of a leg ulcer venosum. It mainly occurs in the lower part of the lower leg. A venous leg ulcer, in most cases, has a very large extent and may also encompass the legs altogether.

Ulcus cruris arteriosum

Less often, narrowing of the arterial circulation is responsible for circulatory disorders (peripheral vascular disease, PAOD). Physicians then speak of a leg ulcer. It arises in most cases as a result of simple leg injuries. These can not heal properly due to the lack of supply of arterial, oxygen-rich blood and ignite. An ulcus cruris arteriosum usually occurs on the toes or on the sole of the foot.

Ulcus cruris mixtum

In addition, an open leg can also be caused by a concomitant constriction of both bloodstreams – the venous and the arterial vascular system (ulcus cruris mixtum).

Ulcus cruris neoplasticum

The fourth form is the ulcus cruris neoplasticum. In this form, the wounds on the lower leg caused by malignant growths.

Furthermore, a leg ulcer often arises as a result of diabetes mellitus (diabetes). Doctors also speak of a diabetic foot.

A lower leg ulcer as a result of circulatory disorders is relatively common. The risk of developing a leg ulcer increases significantly with age. People under the age of 40 are very rarely affected, whereas in people over 80, leg ulcers are relatively common. Men and women are affected about equally frequently.

Ulcus cruris: symptoms

The symptoms of a leg ulcer may vary slightly depending on the nature of their development. Classically, ulcus cruris has deep wounds that do not heal on its own, like other injuries. They penetrate several skin layers and can even reach to the bones. In most cases the wounds are moist and wet permanently. This means that from the inside a clear, slightly slimy liquid emerges. This fluid causes the surrounding skin to soften. Doctors speak of macerations.

A venous leg ulcer is usually located in the area of ​​the ankle and enlarges in the direction of the lower leg. Such a venous open leg often takes on a so-called galoshes form, in which the wound winds once around the leg.

A venous ulcer causes in most cases a constant feeling of tightness in the affected extremities. On the other hand, pain is rare. The emigration of red blood cells from the surroundings of the ulcus cruris causes the skin around the wound to become often brownish.

Arterial open legs are contrary to their name rather in the area of ​​the feet than the legs. Especially common are arterial ulcers on the toes and the sole of the foot. In contrast to ulcus cruris venosum, ulus cruris arteriosum is associated with severe pain in the legs. In particular, these occur during movement or when the leg is stored up. In a leg ulcer, the feet are also usually cold and pale.

In all forms of leg ulcers nail growth may be disturbed. Also, the toenails may be discolored or brittle.

Symptoms of improper care

The wounds in a leg ulcer can easily become infected, especially if they are not expertly cared for. If the wounds are open or possibly get dirt or dust in, bacteria or other pathogens can easily get into the wound. A bacterial infection usually leads to inflammation. Inflamed ulcus cruris is manifested among other things by a pungent, foul smell, which is equally unpleasant for those affected and their environment.

Incorrect treatment often complicates ulcus cruris. Many sufferers believe that they can treat the wounds themselves with different creams or ointments. However, this does not cure a leg ulcer. The result is often the opposite: many sufferers develop a so-called contact dermatitis. This is an allergic rash that is caused by the ingredients of the creams. Contact dermatitis is characterized by redness, itching and / or burning of the affected skin.

Ulcus cruris: causes and risk factors

A leg ulcer is caused by a lack of blood in certain areas of the body. For this shortage of various causes come into question. Most common cause of open leg2 is a narrowing of the venous vessels. In addition, a narrowing of the arterial vessels may cause an open leg. In rare cases, other factors are involved in the development of the ulcus cruris.

Venous causes

Veins are called blood vessels that return blood from the body back to the heart. Venous ulcers arise as a result of chronic venous insufficiency (chronic venous insufficiency, CVI). This can be caused, among other things, by blood clots in the deep leg and pelvic veins (thrombosis).

In the case of chronic venous insufficiency, the veins dilate and extend – causing varicose veins. The enlargement causes the blood can not be transported so well to the heart. As a result, there is a stagnation of the blood in the veins. As a result, water accumulates in the surrounding tissue and edema forms. If edema persists for a long time, hardening of the surrounding connective tissue may occur. Doctors call this a sclerosis. These changes no longer supply the tissue with sufficient oxygen and nutrients that are normally transported through the blood and distributed throughout the body. This undersupply leads after a long time to foot and leg ulcers.

All sequelae of thrombosis of the deep leg and pelvic veins (such as congestion, swelling, venous leg ulcers) are summarized under the term “postthrombotic syndrome”.

Arterial causes

Arteries are blood vessels that carry blood away from the heart. They distribute oxygen and nutrients in the body. Various factors can lead to deposits of lime or connective tissue on the wall of the arteries. This arteriosclerosis is called arteriosclerosis. By calcification, the inner diameter of the arteries becomes narrower, and less blood and thus less nutrients and oxygen get into the tissue. This undersupply also creates an open leg.

The most important risk factor for arteriosclerosis is smoking. It promotes the formation of vascular deposits in all vessels of the body. Further risk factors for arteriosclerosis-related leg ulcers are high blood pressure (hypertension) and high blood lipid levels (hyperlipidemia).

Other causes of leg ulcers

Another risk factor for the development of a leg ulcer is the diabetes mellitus diabetes mellitus. There are several factors that support the formation of a leg ulcer. These include primarily the increased calcification of the arteries (arteriosclerosis).

Diabetic polyneuropathy can also support the development of ulcus cruris. This diabetes-related nerve damage affects mainly the nerves in the feet: As a result, the sensibility in the feet and legs is lost. The often resulting malposition of the feet favor the formation of wounds. If these heal poorly or if new sores develop again and again, a leg ulcer may form.

Ulcus cruris: examinations and diagnosis

If you suspect that a leg ulcer develops or already exists, the family doctor or a dermatologist is the right person to contact. Most of these recognize a leg ulcer at first glance. However, when choosing the right therapy, it is important to know what the exact cause of the ulcus cruris is. Therefore, first of all, a detailed survey of the medical history (anamnesis) takes place. In doing so, you should describe to the doctor your complaints and physical changes that you have noticed as precisely as possible. The doctor may also ask questions like:

• Have you ever had similar symptoms in the past?
• Have you noticed any limitations on your performance, for example, do you stop more often than before?
• Do you have the impression that the wound has become larger or smaller or has remained the same?

After a thorough examination of the sore spot, the physician can perform a Doppler sonography, a form of ultrasound examination that displays venous and arterial blood flow conditions. If the cause of the leg ulcer lies in a reduced blood flow, the doctor can detect this directly in the Doppler sonography.

The reason for a decreased blood flow may be different. In many cases, the circulatory disorder is due to blood clots in the veins. Such thromboses can be detected by means of an X-ray examination in which a contrast agent is injected beforehand. Such an X-ray contrast examination is harmless. After spraying the contrast medium, it may possibly lead to cold feelings. Nausea also occurs occasionally. These symptoms disappear within a few hours.

Also, a blood test is routinely made. With their help, for example, it can be clarified whether a diabetes mellitus (diabetes mellitus) or a coagulation disorder exists. The evaluation of the blood sample usually takes several days. If all other examinations point to an open leg, treatment is started before the final evaluation of the blood sample.

If there is a suspicion of infection of the ulcus cruris, for example with bacteria, the doctor also takes a swab from the wound. This sample is examined in the laboratory. It can give clues to the cause of the inflammation.

In rare cases, a spinal egg (a form of skin cancer) may be the cause of a leg ulcer. This can be clarified by means of a tissue sample (biopsy).

Ulcus cruris: treatment

The treatment of a leg ulcer is often difficult and tedious. The aim of the treatment is primarily to eliminate the causes of the ulcus cruris, so usually to improve the disturbed blood reflux. In addition, the wound must be treated so that it heals quickly. Last but not least, an additional infection must be prevented. The therapy of the ulcus cruris usually lasts several weeks. Even after completion of the therapy regular check-ups by the doctor should continue.

Improvement of blood flow

The improvement in blood flow is in most cases initially attempted by compressive bandages. These increase the pressure in the vessels and ensure that the blood flows faster again. These bandages can be applied regularly by a doctor or a medical assistant. Affected patients can also create such a bandage themselves after they have learned how to do it.

In addition, people with a leg ulcer should move a lot. This also stimulates blood flow and prevents blood from accumulating in the lower leg.

wound cleansing

The treatment of the open wound is done by the doctor. The wound must be regularly cleaned and disinfected. This is done either with special ointments, which dissolve the coverings on the wound (fibrinolytic ointments), or by means of the so-called curettage. During curettage, the doctor removes the pads with a sharp spoon and cleans the wound. Then envelopes are applied with antiseptic agents. Through this, the wound should be kept germ-free. For heavily weeping wounds, moist envelopes with saline solution are used.

In chronic wounds, a so-called moist wound treatment takes place. There are different editions available. These pads keep the wound free from pathogens and dirt, and promote the regeneration of the surrounding skin. Moist wound dressings tend to enhance healing rather than a completely dry treatment.

Wound cleaning with fly larvae

A very effective treatment of ulcus cruris is the bio-enzymatic wound cleansing with fly larvae. Here, 100 to 200 fly larvae are placed in a porous bag on the ulcer for two to three days. The larvae feed on dead tissue that they have previously thawed by their saliva. Living tissues do not attack the larvae. Especially with poorly healing, infected wounds that do not respond to antibiotic therapy, this method is recommended.

Operational measures

In a leg ulcer, surgical methods may also be used to cleanse the wound, remove debris, improve venous blood flow, and accelerate wound healing. For example, varicose veins that run onto the leg ulcer can be removed surgically. Alternatively, they can also be sclerosed (sclerotherapy).

For arterial leg ulcers, surgical treatment in the form of a bypass surgery may help. The narrowed or closed vessel section is bridged by displacing a section of vessel from another location in the body, which is not absolutely necessary there, to the narrowed section.

Some leg ulcers can also be healed faster by surgical skin transplantation.

drugs

In the case of a particularly stubborn lower leg ulcer, supplemental medication may be provided by the Ulcus-cruris therapy. This medication, which contains growth factors, prescribed. This also supports wound regeneration. Antibiotics are prescribed if there is an additional bacterial infection.

Cortisone in contact dermatitis

Patients often provide their open legs with different creams themselves. Not infrequently, an allergic reaction (so-called contact dermatitis) develops. This allergic reaction can be reduced within a few days using local cortisone therapy (cortisone-containing cream).

Ulcus cruris: Disease course and prognosis

The prognosis of a leg ulcer depends on the severity of the symptoms, the type of ulcer and the individual conditions. Generally, a venous open leg heals better than an arterial ulcus cruris. However, ulus cruris venosum is more likely to re-form within a short time. The risk of relapse can be reduced by carrying out the follow-up treatment of the leg ulcer consistently. In particular, this means that affected persons move more and continue the compression therapy even after healing of the ulcus cruris.

With a consistent therapy, a leg ulcer often heals completely within a few months. However, especially in the elderly, healing can last for many years. Older people generally have more risk factors for leg ulcers than younger people. In addition, the regeneration capacity of the skin is often already limited in older people. To make matters worse, many older people do not consistently follow a therapy, which delays healing.

The longer an ulcus cruris remains untreated, the greater the risk of grave consequences. Especially with arterial ulcus cruris there is a risk that the tissue dies (necrosis). In severe cases, it may be necessary to amputate affected toes or legs to prevent spreading necrosis. Certain individual conditions additionally increase the risk of amputation due to ulcus cruris. These include primarily smoking or poorly adjusted blood sugar in diabetes mellitus.

How to prevent a leg ulcer and improve the prognosis

You can prevent a leg ulcer in different ways or improve the prognosis of an existing leg ulcer.

For a venous leg ulcer, compression therapy is especially important. Wearing compression bandages or compression stockings significantly improves blood flow and prognosis. Concerned individuals should also move a lot to boost blood circulation. For sedentary activities, you should regularly take small breaks to move. If possible, you can sit with your legs over your heart while sitting down. This also improves the blood flow. When standing, you should change position from time to time. Obese people should urgently reduce their body weight.

Smoking is the most important factor in arterial leg ulcers. Smoking significantly increases the risk of developing a leg ulcer. For those already affected, smoking retards healing and increases the rate of relapse. Even with an arterial ulcus cruris, it is important to reduce your own body weight and to move regularly. It is also important to wear shoes in which the feet feel comfortable and are not pinched. Care should be taken during foot care to avoid injury to the feet. In particular, diabetics should go regularly to medical foot care to reduce the risk for one Leg Ulcer to lower.