Ulceration of the skin is defined as complete epidermal loss, thus exposing dermal (or deeper) layers. ‘Leg ulcer’ is not a diagnosis. Making a comprehensive diagnosis is the key to management. Ulcers on the lower leg are frequently caused by vascular disease, particularly, at least in part, venous hypertension. For each cause of leg ulceration there are several different underlying pathologies that have to be considered.
A detailed history of the onset and course of leg ulceration and predisposing conditions should be taken. The site and surrounding skin should be assessed. Varicose veins are often present, although not inevitably. The site of ulceration may help indicate the cause.
Appropriate investigations include:
- Urinalysis for glycosuria.
- Full blood count to detect anaemia and blood dyscrasias.
Leg ulceration due to venous disease.
Varicose veins, a history of deep venous thrombosis and obesity are predisposing factors. Incompetent valves in the deep and perforating veins of the lower leg result in retrograde flow of blood to the superficial system, and a rise in capillary pressure (‘venous hypertension’). Pericapillary fibrin cuffing occurs, leading to impairment of local tissue oxygenation and homeostasis. The first symptom in venous ulceration is often heaviness of the legs, followed by oedema. Haemosiderin pigmentation, pallor and firmness of surrounding skin, and sometimes venous/gravitational eczema subsequently develop. This progresses to lipodermatosclerosis – firm induration due to fibrosis of the dermis and subcutis, which may produce the wellknown ‘inverted champagne bottle’ appearance. Ulceration, often precipitated by trauma or infection, follows. Venous ulcers typically occur on the medial lower leg
Leg ulceration due to arterial disease
Deep, painful, punched-out ulcers on the lower leg, especially the shin and foot and in the context of intermittent claudication, are likely to be due to arterial disease. Risk factors include smoking, hypertension, diabetes and hyperlipidaemia. The foot is cold and dusky and the skin atrophic and hairless. Peripheral pulses are absent or reduced. If the ABPI is below 0.8, a vascular surgical assessment should be sought.
Leg ulceration due to vasculitis
Vasculitis can cause leg ulceration directly through epidermal necrosis due to damage to the underlying vasculature or indirectly due to neuropathy (e.g. in systemic polyarteritis nodosa, Leg ulceration due to neuropathy The most common causes of neuropathic ulcers are diabetes and Hansen’s disease (leprosy). Microangiopathy also contributes to ulceration in diabetes. The ulcers occur over weight-bearing areas, such as the heel. In the presence of neuropathy, protection of skin from trauma is essential to prevent ulceration.
Making a diagnosis is the first step. General advice on exercise, weight loss and smoking cessation is important. Underlying factors, such as diabetes or anaemia, must be treated. Oedema must be reduced by leg elevation and, if there is no arterial compromise, graduated compression bandaging from toes to knees to enhance venous return and improve healing. Compression bandaging is effective for individuals with an ABPI of more than 0.8 but should be avoided if the ABPI is less than 0.8.
Fluoricum Acidum – Homeopathic Medicine for Varicose Ulcers with Burning Pain. Fluoricum Acidum is a homeopathic medicine used to treat varicose ulcers that come with severe burning pains.
Lachesis Muta – Homeopathic Medicine for Sensitive Varicose Ulcers. Lachesis Muta is a homeopathic medicine used to treat varicose ulcerss when the surface of the ulcer is uneven and looks dirty, and purplish, bluish-blackish skin may surround it. There may be a burning sensation in the ulcers at night. This medicine is indicated for varicose ulcers that arise from an injury.
Calendula Officinalis – Homeopathic Medicine for Varicose Ulcers with Pus Discharge. Calendula Officinalis is a homeopathic medicine used to treat varicose ulcers with lot of pus discharges. Inflammation, stinging and pain in the ulcer is present and the ulcer is deep, with red, ragged edges. This medicine is also used as a preventive measure against gangrene development.
Carbo Veg – Homeopathic Medicine for Varicose Ulcers with Bleeding. Carbo Veg is a homeopathic medicine used to treat varicose ulcers that bleed easily, even on the slightest touch. The ulcer has a purple color and the skin surrounding it feels tense. Foul-smelling pus discharges with blood may also be present.
Pulsatilla Nigricans – Homeopathic Medicine for Varicose Ulcers with Itching. Pulsatilla Nigricans is a homeopathic medicine used to treat varicose ulcers that itch. The ulcer looks red and is hard to touch. Symptoms, like smarting and shooting pain, burning, stinging and excoriating sensation in the ulcer that get better on exposure to cold or open air, are present. In some cases, a greenish, yellowish discharge may also be present.