Trophic ulcer is an open wound on the skin or mucosa that has arisen after the rejection of dead tissues and does not heal for 6 or more weeks. The cause of trophic ulcers is a local violation of blood circulation or tissue innervation. Pathology develop against the background of various diseases, are characterized by a persistent long course and are difficult to treat. Diagnostics is carried out by ultrasound methods. Recovery directly depends on the course of the underlying disease and the possibility of compensating for the disorders that led to the appearance of ulcers.
ICD 10
I83.0 I83.2
Meaning
Trophic ulcer is a long—term non-healing defect of the skin and the tissues located under it. Varicose trophic ulcers often occur in the lower third of the lower leg against the background of varicose veins. A cyanotic painful spot appears on the edematous limb, then small ulcers that gradually merge into one defect. A bloody or purulent discharge oozes out of the ulcer, often with an odor. The course is recurrent, progressive, complete cure of varicose trophic ulcers is possible only with the removal of altered veins. Clinical phlebology deals with the diagnosis and elimination of the causes of trophic ulcers in such cases.
Causes
The occurrence of trophic ulcers can be caused by any disease of the superficial or deep veins, accompanied by chronic venous insufficiency. When making a diagnosis, the disease that caused the formation of ulcers is very important, since the treatment tactics and prognosis largely depend on the nature of the underlying venous pathology. The development of trophic ulcers can lead to:
- chronic venous insufficiency (with varicose veins, post-thrombophlebitic disease);
- deterioration of arterial circulation (with hypertension, diabetes mellitus, atherosclerosis);
- violation of lymph outflow (lymphedema);
- injuries (frostbite, burns);
- chronic skin diseases (eczema, etc.).
Trophic ulcer can develop with chromium or arsenic poisoning, some infectious diseases, systemic diseases (vasculitis), local circulatory disorders with prolonged immobility as a result of illness or injury (bedsores). More than 70% of all trophic ulcers of the lower extremities are caused by venous diseases.
Pathogenesis
Violation of venous blood flow caused by diseases of the venous system leads to the deposition of blood in the lower extremities. The blood stagnates, the waste products of cells accumulate in it. Tissue nutrition is deteriorating. The skin is compacted, soldered with subcutaneous tissue. Dermatitis, wet or dry eczema develop.
Due to ischemia, the healing process of wounds and scratches worsens. As a result, the smallest damage to the skin in chronic venous insufficiency can cause the development of a long-term, poorly treatable trophic ulcer. The addition of infection aggravates the course of the disease and leads to the development of various complications.
Symptoms
The development of a trophic ulcer of venous etiology is preceded by the appearance of characteristic signs of a progressive lesion of the venous system. Initially, patients note an increase in swelling and a feeling of heaviness in the calf area. Nocturnal muscle cramps are becoming more frequent. There is an itching, a feeling of heat or burning. Hyperpigmentation increases, its zone expands. Hemosiderin accumulating in the skin causes eczema and dermatitis. The skin in the affected area acquires a varnished appearance, thickens, becomes motionless, tense and painful. Lymphostasis develops, leading to lymph transudation and the formation of small droplets on the skin that look like dew.
After a while, a whitish focus of epidermal atrophy appears in the center of the affected area (pre–ulcer condition – white atrophy). With minimal damage to the skin, which can pass unnoticed for the patient, a small ulcerative defect forms in the area of atrophy. In the initial stage, the trophic ulcer is located superficially, has a moist dark red surface covered with a scab. In the future, the ulcer expands and deepens. Individual ulcers can merge with each other, forming extensive defects. Multiple neglected trophic ulcers in some cases can form a single wound surface along the entire circumference of the lower leg.
The process extends not only in breadth, but also in depth. The penetration of ulcers into the deep layers of tissues is accompanied by a sharp increase in pain. Ulcerative lesions can capture the calf muscles, Achilles tendon and periosteum of the anterior surface of the tibia. Periostitis, complicated by a secondary infection, can turn into osteomyelitis. When soft tissues are damaged in the ankle joint, arthritis occurs with the subsequent development of contracture.
The nature of the discharge depends on the presence of a secondary infection and the type of infectious agent. In the initial stages, the discharge is hemorrhagic, then cloudy with fibrin filaments or purulent with an unpleasant odor. Maceration of the skin around a trophic ulcer often leads to the development of microbial eczema.
Complications
When an ulcer is infected, the risk of complications increases. As a rule, secondary infection is caused by conditionally pathogenic bacteria. In elderly weakened patients, it is possible to attach a fungal infection, which aggravates the course of the disease, causes rapid progression of trophic disorders and worsens the prognosis.
Trophic ulcers are often accompanied by pyoderma, allergic dermatitis. Lymphangitis, purulent varicothrombophlebitis, erysipelas, inguinal lymphadenitis may develop. In some cases, trophic ulcers are complicated by phlegmon and even sepsis. Recurrent infection causes damage to the lymphatic vessels and leads to the development of secondary lymphedema.
Diagnostics
Confirmation of the venous etiology of trophic ulcers is concomitant varicose veins and phlebothrombosis. The high probability of deep vein thrombosis is indicated by the presence in the anamnesis of diseases of the blood system, hormonal medications, catheterizations and puncture of the veins of the lower extremities, episodes of prolonged immobility during injuries, chronic diseases and surgical interventions.
A typical localization of a venous trophic ulcer is the inner surface of the lower third of the lower leg. The skin around the ulcer is compacted, pigmented. Eczema or dermatitis is often observed. During palpation, crater-like dips can be detected in the area of trophic disorders (places where altered communicating veins exit through the fascia of the lower leg). Varicose veins are visually revealed, most often located on the medial and posterior surfaces of the lower leg and the posterior surface of the thigh.
To assess the state of the venous system, the following:
- functional tests are carried out;
- ultrasound of the veins of the lower extremities, ultrasound duplex examination;
- for the study of microcirculation, rheovasography of the lower extremities is indicated.
Trophic ulcers of venous etiology often develop in elderly patients with a whole “bouquet” of concomitant diseases, therefore, treatment tactics should be determined only after a comprehensive examination of the patient.
Treatment
In the process of treating a trophic ulcer, a phlebologist must solve a whole range of tasks. It is necessary to eliminate or, if possible, minimize the manifestations of the underlying disease that caused the formation of ulcers. It is necessary to fight the secondary infection and treat the trophic ulcer itself.
General conservative therapy is carried out. The patient is prescribed drugs for the treatment of the underlying disease (phlebotonics, antiplatelet agents, etc.), antibiotics (taking into account the sensitivity of the microflora). Locally, enzymes and laser treatment are used to purify trophic ulcers; local antiseptics are used to combat secondary infection, and wound–healing ointment dressings are used after inflammation is eliminated. With extensive defects, skin plastic surgery of a trophic ulcer may be indicated.
Surgical treatment of causal pathology is carried out after preparation (ulcer healing, normalization of the general condition of the patient). Perform operations aimed at restoring venous blood flow in the affected area: bypass surgery, removal of varicose veins (miniflebectomy, phlebectomy).
Prevention
Preventive measures consist in early detection and timely treatment of varicose veins. Patients suffering from varicose veins and post-thrombophlebitic disease should use elastic compression products (therapeutic knitwear, elastic bandages). Follow the doctor’s recommendations, avoid prolonged static loads. Patients with chronic venous insufficiency are contraindicated to work in hot shops, prolonged hypothermia, work in a stationary state. Moderate physical activity is necessary to stimulate the muscle pump of the shins.
Literature
- Gottrup F, Apelqvist J, Price P, European Wound Management Association Patient Outcome Group. Outcomes in controlled and comparative studies on non-healing wounds: recommendations to improve the quality of evidence in wound management. Journal of Wound Care. 2010;19:(6):237-268
- Lobastov, K., et al., Electrical calf muscle stimulation with Veinoplus device in postoperative venous thromboembolism prevention. International angiology. 2014;33(1):42-49
- Vanessa Jones, Joseph E. Grey, and Keith G. Harding. ABC of wound healing. Wound dressings. BMJ. 2006;332(7544):777-780
- National Health Service. Venous leg ulcer. — 2019.
