Venous, Arterial, and Neuropathic Leg Ulcers With Emphasis on the Geriatric Population

Abstract

Leg ulcers are a common and often serious problem in older adults. Underlying conditions that increase risk include age-related increases in chronic venous insufficiency, peripheral artery disease, connective tissue and autoimmune conditions, reduced mobility, and diabetes mellitus (DM). Geriatric patients have a higher risk of multiple wound-related complications including infection, cellulitis, ischemia, and gangrene, any of which may lead to further complications including amputation. The very presence of these lower extremity ulcers in the elderly negatively impacts their quality of life and ability to function. Understanding and early identification of the underlying conditions and wound features are important for effective ulcer healing and complication mitigation. This targeted review focuses on the three most common types of lower extremity ulcers: venous, arterial, and neuropathic. The goal of this paper is to characterize and discuss the general and specific aspects of these lower extremity ulcers and their relevancy and impact on the geriatric population. The top five main results of this study can be summarized as follows. (1) Venous ulcers, caused by inflammatory processes secondary to venous reflux and hypertension, are the most common chronic leg ulcer in the geriatric population. (2) Arterial-ischemic ulcers are mainly due to lower extremity vascular disease, which itself tends to increase with increasing age setting the stage for an age-related increase in leg ulcers. (3) Persons with DM are at increased risk of developing foot ulcers mainly due to neuropathy and localized ischemia, both of which tend to increase with advancing age. (4) In geriatric patients with leg ulcers, it is important to rule out vasculitis or malignancy as causes. (5) Treatment is best made on a case-by-case basis, considering the patient's underlying condition, comorbidities, overall health status, and life expectancy.

Keywords: arterial ulcers; arterial-ischemic ulcers; chronic leg ulcers; chronic venous ulcers; diabetic ulcers; evaluation of ulcers; leg ulcers; management of leg ulcers; neuropathic ulcers; venous ulcers.

Figure 1. Venous ulcer located on the lateral gaiter area

These ulcers typically have an irregular shape and characteristic wound bed granulation tissue and surrounding tissue hyperpigmentation. The figure is provided as a courtesy of Dr. HN Mayrovitz.

Figure 2. Schematic of the impact and hemodynamics of incompetent venous valves

The normally low pressure experienced by the superficial veins is subject to high pressures in the presence of valve incompetency as shown in part B. This elevated pressure is not well tolerated and causes venous injury that triggers a sequence of events that may lead to the development of a venous ulcer. This figure is provided as a courtesy of Dr. HN Mayrovitz.

Figure 3. Periulcer skin blood perfusion measurement

A laser Doppler probe is fitted through a concentric hole in the heater that is in contact with the skin. Localized heating produces an increase in microvascular perfusion in the healthy skin but with a different pattern in the peri-wound skin as shown in Figure 4. This figure is provided as a courtesy of Dr. HN Mayrovitz.

Figure 4. Skin blood perfusion responses to heating in healthy vs. periulcer skin

The responses show a normal response to localized heating (A) and a common finding associated with venous ulcers (B). In part B, an elevated periulcer basal resting perfusion is noted with little if any microvascular reserve when stimulated with heat. In contrast, in the control skin as shown in part A, a normal active hyperemia is noted in response to the heating. This figure is provided as a courtesy of Dr. HN Mayrovitz.

Figure 5. Some aspects of an arterial ulcer

A patient with critical ischemia due to significant PAD in whom toes 2-3 were previously amputated and toe 5 is necrotic. This figure is provided as a courtesy of Dr. HN Mayrovitz.

Figure 6. A common site of a plantar diabetic neuropathic ulcer

This figure is provided as a courtesy of Dr. HN Mayrovitz.