Aging Begins at 30

Leg Ulcers Can Be Complicated

Juanita told me through an interpreter "It's only a leg ulcer, isn't it?" She was a diabetic and I was cautious in answering that question. "Let's be sure we know what caused the ulcer and then we can tell you if its "only" a leg ulcer," I said.

Ulcers of the leg can be an inconvenience or of great seriousness. They fall into two main categories, venous and arterial, and into four most common types (although there are over 50 causes), venous insufficiency, large artery disease, small artery disease (such as occurs in diabetes), and nerve deprivation. They've been known since the time of Hippocrates and U.S. estimates indicate half a million cases yearly in the U.S. Under 40, the sexes are affected evenly, women over 40 are affected more than men, and over age 70 they have three times as many leg ulcers as men.

Patients with venous ulcers may come with a history of white leg in pregnancy (thrombophlebitis) or show evidence of venous valvular incompetence with swollen ankles. The venous ulcer is based on thick, leathery, unyielding, pigmented skin with ankle swelling and dilated tortuous superficial veins. Venous ulcers are found over the inside ankle bones or over the shins. Venous ulcers are superficial, have uneven edges, a base of ruddy proud flesh, and are moderately painful. Arterial ulcers are the result of hardened arteries, advanced age, and diabetes. Arterial ulcers are thin, dry, shiny on hairless skin. The limb goes pale on elevation of the leg and shiny red-blue when dependent. Arterial ulcers show between the toes, at the tip of the toes, under the base of the toes, or on the outside ankle bones at areas of pressure. Arterial ulcers have well demarcated edges, may be black, have a deep pale base, and can be exceedingly painful.

The doctor asks "How did it begin? What did the ulcer look like first? Was there any injury or burn? How painful is it? What diseases do you have or run in your family? What drugs are you taking or putting on the ulcer? Do you stand a lot? Do you smoke and how much alcohol do you drink?" He or she will feel for pulses behind your inside ankle bone or in the cleft between your big and next toe. If the pulses cannot be felt, this may be an arterial or blood starved ulcer and Doppler tests will be done. Dr. Doppler was a physicist who noted that trains coming toward you sound different from those going away from you and the sound can be used to measure flow and pressure in the arteries.

About three-quarters of all ulcers are venous and half of these will occur after deep vein clotting (phlebitis) and half due to incompetent valves between the superficial and deep veins. Then the 3 to 5 feet of pressure above your ankles can blow out valves in the leg veins and cause dirty stains from altered blood and lead to ulceration.

In treating ulcers, first, do no harm. Many ulcer patients get reactions from to the local preparations they use. Others tear off new skin covering when they take off their dressings. Some burn their feet on hot water bottles or from hot soaks. Treatment is difficult and lengthy.

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See related Patient Topics Bones, Joints and Muscles, Injuries and Wounds or Leg Injuries and Disorders.

See related Provider Topics Bones, Joints and Muscles or Injuries and Wounds.

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