Chronic leg ulcers: The impact of venous disease☆☆☆

Prevalence of leg ulcers 

Differences in leg ulcer prevalence between various studies may have several causes, such as the use of overall or point prevalence, the inclusion or exclusion of foot ulcers, the age and sex distribution in the patient series, and the methodology of identifying patients. With a combination of questionnaires to the health care system (eg, wards, outpatient clinics, nurses) and questionnaires to randomly selected individuals within the population and a thorough investigation of the random samples of responders, it would seem as if an optimal estimate is obtained. We have been especially interested in an investigation of the ulcer situation in three Swedish regions—the city of Malmö (urban population), the county of Skaraborg (rural population), and the county of Uppsala (mixed population). The populations in the three regions are fairly similar (250,000 to 300,000 inhabitants).

One obvious problem is the large number of patients, especially younger male patients, who are not known to the health care system.6, 7 These patients take care of the ulcers themselves, and among them, there are, without doubt, patients with curable diseases, such as superficial venous insufficiency. The overall or lifetime prevalence is roughly three times higher than the point prevalence, and there is a clear increase with age (Table I).

Table I. Overall prevalence of leg ulcer in Skaraborg county (%)

		Known to health care system		Self care included
		All causes	Venous	All causes	Venous
	Total population	0.90	0.49	1.90	1.03
	>15 years old	1.20	0.65	2.40	1.30
	>64 years old	4.20	2.27	5.60	3.02

Causes and characteristics of leg ulcers 

There are many causes of leg ulcers. The problem is even greater in that one patient may have several causes and that this may vary with time. So, a patient with a long-standing, pure venous ulcer may have arterial insufficiency develop with increasing age, which adds to the problem and makes treatment more difficult. One etiological classification is exemplified in Table II, where there is a combination of clinical and physiologic findings and the clinician decides on the most probable cause.

Table II. Etiologic classification of chronic leg ulcers with examples from the Skaraborg study3 (%)

	Etiologic classification	No. of ulcers above the foot (n = 353)	No. of isolated foot ulcers (n = 110)
	Venous	52	2
	Mixed venous/arterial*	18	1
	Mixed arterial/venous†	4	5
	Arterial	4	19
	Arterial and diabetes	2	34
	Diabetes	1	14
	Traumatic	2	1
	Pressure	<1	13
	Multifactorial (arterial, venous,	3	3
	diabetes)
	Multifactorial (others)	8	4
	Other single causes	6	4

The classification was made by one surgeon who combined clinical and physiologic findings. *Venous cause dominating. †Arterial cause dominating.

Table III. Causes of chronic leg ulcers (%)

		Skaraborg county	Uppsala county	Malmö city
		(n = 463)	(n = 406)	(n = 257)
	Venous	40	29	34
	Mixed	18	14	11
	Arterial/diabetes	21	8	21
	Traumatic	2	18	2
	Others	19	31	32

All ulcers, including foot ulcers, are included.

The distribution of venous insufficiency in 463 legs with current ulcers3 can be seen in Table IV.

Table IV. Distribution of venous insufficiency in 463 legs with current ulcers (%)

		Ulcer above the foot	Foot ulcer
	Femoral vein	27	4
	Popliteal vein	45	15
	Long saphenous vein	31	9
	Short saphenous vein	44	16
	Calf perforators	56	13

As understood from summarizing the columns, there are various types of combinations.

There are several important differences between venous and nonvenous ulcers, some of which are shown in Table V.

Table V. Comparison between venous and nonvenous chronic leg ulcers

		Venous	Nonvenous	P value
	Median patient age (years; range)	77 (39 to 97)	77 (13 to 91)
	Diabetes (%)	8	47	<.001
	History of thrombosis (%)	37	11	<.0001
	Median age at first ulcer (years; range)	59 (14 to 92)	73 (12 to 94)	<.001
	Median duration of ulcer history (years)	13.4	2.5	<.001
	Recurrent ulcer (%)	72	45	<.001

Socioeconomic factors 

To analyze the socioeconomic factors, 78 patients with leg ulcers were compared with 271 control patients without ulcers, all of whom were identified in a population survey in Malmö and Skaraborg.5 Except for a significantly lower income in the ulcer group, there was a surprising lack of differences in socioeconomic factors. So, 74% of the patients with ulcers earned less than $12,500 per year as compared with 50% of the patients without ulcers. One important factor is the high frequency of immobile patients with leg ulcers. In the Skaraborg study, only 40% walked without some sort of support and 18% used a wheelchair regularly.

Present treatment 

Leg ulcer treatment by tradition has been considered of secondary interest by most health care workers. This is reflected in the large number of various local treatments found in a recent survey in Uppsala county in which 113 types of local wound treatments were identified. Dressing changes were made by district nurses in 52% of the cases, by other health care workers in 40%, by relatives in 2%, and by the patients themselves in 6%. In 6% of the patients with venous ulcers, the dressings were changed 2 to 3 times daily; in 36%, once daily; in 37%, 2 to 3 times a week; and in 21%, once a week.11 In the Skaraborg study, 74% of the patients with venous ulcers used daily compression as compared with 22% of the patients with nonvenous ulcers.11 Pain is a major problem in both venous and nonvenous leg ulcerations.18, 19 In an interview study in the Uppsala county, 89% of all the patients with leg ulcers reported pain. The annual cost of venous leg ulcer treatment in Sweden has been calculated to 250 Swedish Kroner per day, which would be a yearly cost in Sweden of 2 billion SEK.5 This figure excludes the people in selfcare, who induce a substantial indirect cost for the society. Another way to express the cost is that, in a county of Uppsala's size (290,000 inhabitants), 57 nurses were occupied full time with leg dressing changes, which means a cost for salary of approximately 15 million SEK per year.

Prognosis 

In the Skaraborg study, at a mean follow-up period of 54 months, 54% of the venous ulcers were healed, 43% were open, and 3% of the legs were amputated.20 In Uppsala, 40% of the leg ulcers were healed within 3 months. The recurrence of healed venous ulcers is common. In patients with current venous ulcers, as many as 33% have their fourth episode of ulceration and 60% to 70% are already recurrent.11, 21 The long-term outcome for patients with ulcers caused by deep venous insufficiency appears to be worse than for patients with ulcers caused by superficial venous insufficiency or perforating vein incompetence alone.11, 20 To prevent recurrence, adequate compression is extremely important.19, 22, 23 Leg ulcer clinics with dedicated health care personnel, a multidisciplinary approach, and systematic care programs can at least improve the short-term healing of ulcers in the community.24, 25 Treatment in leg ulcer clinics also seems to give a better quality of life.26 Patients with leg ulcers, as a group, have a significantly decreased 5-year survival rate as compared with a matched control population (67%).20 However, with the analysis of patients with ulcers on the basis of cause, patients with venous ulcer have a normal expected survival rate, whereas those with arterial ulcers and ulcers of other causes have a significantly decreased survival rate. Thus, patients with venous leg ulcers are likely to live with their ulcers for a long period of their life unless a curative treatment is offered.

Concluding remarks 

The problem of leg ulcers seems to remain. The enormous costs to the society of leg ulcers have been realized. An often complex etiology makes diagnosis and proper classification of ulcers essential to provide optimal treatment. There is enough basic information to organize effective treatment pathways. A multidisciplinary approach seems to be a prerequisite for improvements in leg ulcer care. A substantial proportion of so-called “chronic” leg ulcers are not chronic provided that adequate treatment is given. Today there should be knowledge enough to substantially decrease the size of the leg ulcer problem.