Ulcus cruris is the medical term for a leg ulcer. Ulcus stands for a long-lasting (= chronic), non-healing wound that is getting larger and deeper. Cruris is the medical term for the lower leg.
Ulcis cruris in a very advanced stage © Source: Wikimedia
The prevalence of leg ulcers in Germany is around 0.5 - 1 percent. In other words, 50-100 out of 1000 people in Germany suffer from leg ulcers, with a total of around 80,000 people affected throughout Germany .
The likelihood of developing the disease is strongly dependent on age and increases to around 2.5 percent from the age of 70. Women are affected more frequently than men. While this problem on the leg hardly ever occurs before the age of 40, the rate of those affected increases above all from the age of 80.
There are various causes for the wound not healing. They are often caused by pathological changes in the arteries and/or veins. However, inflammation of the large and small vessels or bacterial colonization can also be the cause of an ulcer.
The disease most frequently occurs in the area of the lower leg above the ankle. Large ulcers that are located on the inside usually have a venous origin, especially in varicose veins or after thrombosis. In these cases, the leg ulcer is the result of chronic venous insufficiency (CVI) and is referred to as venous leg ulcer.
If the wounds are on the outside of the lower leg, the arteries are usually the cause. In particular, arterial occlusive disease (AVK) should be mentioned here. Vascular calcification(arteriosclerosis) leads to constrictions or occlusions, resulting in a deterioration in tissue perfusion and a reduction in the supply of oxygen. This is referred to as a leg ulcer.
The defect in the tissue usually manifests itself as a painful wound with little tendency to heal.
The first visible sign of a venous leg ulcer is increased pigmentation (brown coloration of the skin). This is due to the fact that blood cells are pushed through the vessel walls into the adjacent tissue as a result of the increased pressure in the veins. There they break down and become visible as brown coloration.
This can be accompanied by yellowing of the skin and so-called atrophy blanche (whitish, thinned areas of skin). In addition, the spider-web-like vascular markings (corona phlebectatica) characteristic of venous insufficiency can be seen on the inner ankle.
Brown discoloration of the skin is one of the first signs of venous leg ulcers © Andrew | AdobeStock
Due to the venous drainage disorder, the metabolic breakdown products can no longer be removed. As a result, the skin cells die (necrosis) and cracks and small injuries develop.
Ulcer-like, poorly healing and often painful wounds form at the bottom of the severely impaired tissue. The ulcers are initially small, but if left untreated they quickly grow into large ulcers affecting the entire lower leg.
An ulcus cruris arteriosum begins with a vascular occlusion. This leads to ischemia (lack of blood supply) of the tissue and tissue loss with ulceration.
As the disease progresses, pain during movement(intermittent claudication) sets in earlier and earlier. The feet and legs are cold, blue and livid (pale) in color.
An ulcus cruris arteriosum manifests itself increasingly distally on the feet, toes and heels. Arterial ulcers are also small and have a round outline with a pale wound bed, which is often covered with fibrin.
In general, all forms of leg ulcers are preceded by reduced blood flow to the affected lower leg tissue. Depending on the underlying cause of this lack of blood flow, a distinction is made between different forms of the disease.
The cause of reduced blood flow is usually venous insufficiency, which can be congenital or acquired. Venous insufficiency can be caused by
can also be caused by pregnancy.
Venous insufficiency leads to congestion in the leg veins. The veins dilate due to the increase in blood volume and develop varicose veins. This leads to inflammatory processes and possibly thrombus formation. The congestion also causes venous hypertension(high blood pressure), which gradually destroys the capillaries. Capillaries are the smallest blood vessels where the exchange of nutrients and gases takes place.
Edema forms in the ankle area, i.e. tissue swelling due to fluid accumulation. The oedema progresses to dermatoliposclerosis, which is a noticeable hardening of the skin and subcutaneous tissue. These changes result in a reduced supply of oxygen and nutrients to the affected tissue.
Lower leg ulcers are also caused by arteriosclerosis of the lower extremities in around 10 percent of cases. Arteriosclerosis causes the arteries to narrow, which can eventually lead to complete blockage of the vessel(peripheral arterial occlusive disease, PAD).
Ulcerated skin layer © ilusmedical | AdobeStock
There is often a mixed form with venous and arterial causes - a mixed leg ulcer. This is caused by the combined presence of PAD and CVI.
In around 10 percent of cases, the leg ulcer is
- caused by an accident (traumatic leg ulcer) or
- due to a tumor disease (neoplastic leg ulcer),
- an infection (ulcus cruris infectiosum) or
- a systemic disease such as rheumatism (ulcus cruris rheumaticum)
can be traced back.
In the case of a classic leg ulcer, the examination is carried out as part of a visual diagnosis, i.e. by visual inspection by the doctor. Changes in the surrounding area are also important for the diagnosis.
Other risk factors that could contribute to the development of the ulcer must, of course, be ruled out.
It is usual to document the healing process of the leg ulcer photographically. If the healing process is unusual, tissue samples are occasionally taken and then bacteriologically tested.
Local therapy begins with wound cleansing. The necrotic tissue is first removed under local anesthesia. An attempt is made to avoid excessive thinning of the lower leg fascia (debridement).
Extensive necrosis is radically surgically removed. Thin necrotic deposits are removed by enzymatic or physical debridement.
Special wound dressings are used for wound care, such as
- hydrocolloids,
- hydrogels,
- alginates,
- polyurethane foam.
They ensure a moist wound environment and promote wound healing.
If the cause is venous (and arterial), compression therapy is the most important component in the treatment of leg ulcers. Compression stockings and compression bandages are used. They minimize the venous congestion problem and improve the disturbed reflux.
Regular exercise is also recommended to support the venous valves and reduce the backflow of blood via the calf muscle pump. Veins in which the backflow is particularly pronounced can be removed as part of a stripping procedure, closed with laser or sclerosed with medication.
In the case of an arterial cause, the circulation situation can be improved by
- medication to thin the blood or
- dissolution of clots (lysis) or
- vascular surgery (bypass operation, balloon dilatation).
can be improved.
A leg ulcer is not just a case for the dermatologist. Depending on the underlying cause, the underlying disease must also be treated by a phlebologist (vascular specialist).
treatment.
With consistent and early treatment, a leg ulcer usually heals completely within a few months. In general, the chances of healing are better for venous leg ulcers than for arterial leg ulcers.
However, the recurrence rate for venous leg ulcers is significantly higher. Recurrence means that the disease develops again after healing. The following is recommended to reduce the risk of recurrence
- to wear appropriate compression stockings,
- to elevate your legs and not cross them, and
- change your working posture from time to time by alternately standing up and sitting down.
The risk factors for leg ulcers are
- smoking
- being overweight
- An unhealthy diet
- lack of exercise
- genetic predisposition
- Diabetes mellitus (diabetes)
- high blood pressure (hypertension) and
- elevated blood lipid levels
Prophylactic measures are therefore recommended:
- Avoiding nicotine consumption
- Exercise and regular sport
- weight reduction
- a healthy and varied diet
- Regular checks of the feet and legs
- Soft and suitable footwear
- avoidance of injuries
