Lower Leg Ulcers - Essay Example

Lower Leg Ulcers Introduction Lower-limb ulceration is becoming a potential health problem in Western countries, particularly in the United States and Canada. Ulcers can be simply referred to wounds that will not heal or keep reoccurring. As researchers like Graham, Harrison, Shafey, and Keast point out, the prevalence of leg ulcers is 1.1-3.0/1000 adults. A variety of problems such as malignancy, infections, and autoimmune disease can be attributed to ulceration. The major gap in the literature is that there are not much documented data or evidence based studies about lower leg ulceration, and hence it is difficult to prepare a comprehensive literature review on the topic. Reviewing the available literature is relevant, because reports indicate that the issue of leg ulcers is mounting significantly today mainly due to lack of knowledge about the prevention and management methods. There are three different types of lower leg ulcers in adults, including venous stasis ulcers, arterial (ischemic) ulcers, and neurotropic (diabetic) ulcers. The literature review gives special emphasis to these three lower leg ulcers in a Canadian perspective. This paper will specifically consider adult victims of leg ulcers in order to analyze the literature well. Venous Stasis Ulcers Venous ulcers, often referred to as stasis ulcers or varicose ulcers, are wounds occurring on the legs due to improper functioning of venous valves. Referring to a research organized by Weller, Ademi, Makarounas-Kirchmann and Stoelwinder (2012), venous ulcers are the main causes of chronic wounds that constitute 70-90% of leg ulcer cases. The authors indicate that it develops along the medial distal legal mainly and this medical condition can be very painful. Venous ulcer is the major cause of lower extremity ulceration and it is growing to be a potential health issue in Canada. In their article titled ‘Diagnosis and treatment of venous ulcers’, Collins and Seraj (2010) say that endothelial damage, intracellular edema, platelet aggregation, and inflammatory processes resulting in leukocyte activation are the major identified causes of venous ulcers. The authors add that older age people and individuals with obesity, venous thrombosis, previous leg injuries, and phlebitis are greatly prone to the risk of developing of venous ulcer. Collins and Seraj point out that venous ulcers seem to be irregular and shallow in physical examination and they are mainly located over bony prominences. Studies indicate that the chance of developing venous ulcers in Western population is relatively high and 10-20/1000 adults in the Western world are likely to be diagnosed with venous ulcer at some point in their lifetime. In order to evaluate the status of venous ulcers in Canada, a group of researchers including Graham, Harrison, Shafey, and Keast (2003) organized a study about various issues concerning this medical condition. For this, the researchers collected responses from physicians who were members of the College of Family Physicians of Canada. Among the participants, 107 physicians reported that 226 patients had been diagnosed with leg ulcers but only a few had undergone ultrasound assessment. When 16% of physicians were confident about managing this complex medical condition, a vast majority (61%) reported that they were not knowledgeable about wound-care products. The researchers noted that over 50% of the participants were unaware of the fact that compression could be an effective treatment for venous ulcers. Referring to the study, the researchers listed a number of issues negatively affecting venous ulcer management. First, physicians often failed to deal with venous ulcer care effectively due to lack of evidence-based clinical practice guidelines. In addition, lack of evidence-based protocols in home care agencies also contributed to inefficient disease management. Finally, poor communication among health care providers and restricted access to wound-care products are some other factors limiting scope of the wound care management (Graham, et al). This study directly reflects that proper venous ulcer management practices such as compression can significantly improve the prevalence of stasis ulcer in the Canadian society. For this, physicians have to be educated on advanced venous ulcer management strategies and effective wound-care products. Arterial (ischemic) Ulcers Arterial insufficiency ulcer, also known as ischemic ulcer, is a type of lower leg ulcer commonly located on the lateral surface of the ankle. According to a study conducted by Spentzouris and Labropoulos (2009), poor blood flow to the capillary beds of the lower extremities results in the development of arterial insufficiency ulcer: and when some sort of pressure is exerted on the skin, the skin gets damaged and becomes unrepairable due to lack of blood flow to the tissue. The wound is usually deep and extends down to the tendons. Like venous ulcers, arterial ulcers are also very painful. As part of disease management, a vascular surgery may be performed to revascularize the area and proper antibiotics are prescribed if infection is present. Once the normal blood flow is established, it is possible to perform debridement. It is advisable for the patient to give rest to foot in case of plantar wounds; otherwise it would lead to enlargement of the ulcer. In addition, patients need to avoid smoking so as to enhance wound healing process. A number of studies have been conducted to get a clear view of arterial ulcers in the Canadian population. Alavi, Mayer, Hafner, and Sibbald (2012) point out that ischemic ulcers are growing in the country and these painful ulcers are most often underdiagnosed. The authors add that this serious medical condition is often associated with hypertension and diabetes. Referring to the studies of Alexiadou and Doupis (2012), wounds in diabetic patients are difficult to cure and this situation in turn would worsen the prognosis of arterial ulcers. The authors say that basic wound care may not be sufficient to heal these ulcers. In his research article ‘management of critical limb ischemia’, Woelk (2012) clearly describes treatments, management, and prognosis of arterial ulcers. Generally, advanced therapies like hyperbaric oxygen therapy or bioengineered skin substitutes are employed to treat these wounds. If arterial ulcers are not treated in time, the affected areas are more likely to become infected and this situation may eventually necessitate leg amputation. In order to analyze the prognosis of this medical condition, Woelk examined cases of arterial ulcers one year after its diagnosis. He found that “25% of patients have died, 30% are living with amputations, 20% have ongoing symptoms, and 25% have symptoms resolved” (Woelk, 2012). From this statistical analysis, it is clear that only one fourth of arterial ulcer victims gained complete cure whereas most others either succumbed to the disease or lost leg. Therefore, ischemic ulcers can be regarded as dreadful conditions that would endanger the victim’s life or adversely affect their quality of life. According to Woelk, the major goals of arterial ulcer management include ‘pain relief and the restoration of skin integrity and function’. The author states that minimizing cardiovascular risk factors is an integral part of the disease intervention and physicians try their best to maintain body functions by avoiding amputation. As the writer points out, prime focus is given to quality of life and operative risk while determining the type of management or intervention technique to be employed. Neurotropic (diabetic) Ulcers Neurotropic ulcers seem to be located at increased pressure points on the feet bottom. However, it is to be noted that neurotropic ulcers related to trauma may be appeared anywhere on the foot. Although this type of lower leg ulcer can develop in any person who has an improper sensation of the feet, it commonly occurs in diabetic patients. The base of the diabetic ulcer is variable and it completely depends on the circulation of the patient. The wounds may appear pink/red or brown/black and the surrounding is most likely to be calloused. It is dreadful to see that neurotropic ulcers and peripheral artery disease occur simultaneously in people with diabetes. Researchers like Sukumar (2000) assert that nerve impairment in the feet may lead to loss of foot sensation and alter the functions of sweat-producing glands; this change in turn would increase the victims’ risk of foot calluses, injury, crack, or infection. In the words of Sukumar, diabetes and leprosy are the two major causes of neurotropic ulcers. In leprosy, superficially placed nerves are damaged; one of such nerves is the ‘posterior tibial nerve that passes below the medial malleolus’ (p.59). It is obvious that pain sensation acts as a protective mechanism to save individuals from serious injuries. According to Sukumar, when nerves in the feet are damaged, the pain sensation is lost and the victim is unaware that tissues of his sole are compressed between the floor and feet bones. The author continues that heel and ball of the great toe are the major parts affected by this condition. The ulcer developed widens soon and “the necrotic material underneath sloughs off leaving a deep ulcer with punched out edges” (p.59). According to the author, neurotropic ulcers can be also very painful. It is easy to understand the reason why diabetic patients are more prone to leg ulcers than other individuals. It is advisable for diabetic patients to inspect their feet daily and to wear proper footwear. One of the notable characteristic features of neurotropic ulcers is that it is easy to prevent although it is difficult to heal. It is better to educate the individual about how this condition occurs and what has to be done to protect his feet (pp. 58-59). In Canada, diabetes mellitus is also growing to be a serious health problem, which in turn increases the risks of neurotropic ulcers. Research studies indicate that neurotropic ulcers occur in a notable percent of diabetics and it is the major cause leading to over 80% of all lower leg amputations. Today several treatment methods are available to combat the serious risks of diabetic ulcers. Wound dressings, hyperbaric oxygen, platelet-rich fibrin therapy, and negative pressure wound therapy are the major techniques used to treat this condition. All the articles discussed above collectively indicate that venous ulcers or varicose ulcers constitute over 80% of the all leg-limb ulceration. In addition, majority of the authors hold the view that a notable percent of physicians is still not aware of the developments in leg ulceration treatments and management. At the same time, authors have different opinions regarding the efficiency of different treatment methods. It is observed that participants of most of the research studies were physicians from the same hospital or institution and therefore study results might not be comprehensive enough to touch different areas of the topic. Discussion of Findings Majority of the physicians are unaware of leg ulcer treatment techniques and other intervention approaches. In addition, they have restricted access to wound-care products. As a result, physicians often fail to deliver effective wound care management services to patients and this situation in turn compromises patient safety. Therefore, proper physician education is necessary to improve leg ulceration management practices in Canada. The arterial ulcers are associated with lack of blood flow to tissues and this situation leads to damage of tissues. Neurotropic or diabetic ulcers raise life-threatening challenges to patients because wounds in diabetic patients are very difficult to heal. This type of ulceration is caused by nerve impairment in the feet and the resulted loss of sensation in the feet. Although it can be a fatal condition, diabetic patients can easily prevent this condition by properly inspecting their feet and shoes daily. Today, many advanced technologies are available for managing lower-limb ulceration. Conclusion From the above discussion it is clear that lower leg ulcers pose serious threats to human health in Canada. Eendothelial damage, intracellular edema, and platelet aggregation can be the major reasons contributing to this serious medical condition. Old age people and obese people are more vulnerable to the risk of developing venous ulcer. Venous ulcer is the most common type of lower leg ulcers and it accounts for roughly two-thirds of all types of ulceration. Poor blood flow to the capillary beds of the lower extremities is the cause of arterial ulcer and a vascular surgery may be often necessary to treat this medical condition. This type of lower leg ulcer is often underdiagnosed. Advanced therapies like hyperbaric oxygen therapy or bioengineered skin substitutes can be effective to manage this health issue. Neurotropic or diabetic ulcers represent the most dangerous lower-limb ulceration because it is more likely to result in leg amputations and death. This type of leg ulcer drastically affects the normal life of diabetic patients. The findings of this paper may not be 100% accurate because there is only limited documented data and evidence about the cases of lower leg ulcers in Canadian adults. References Alavi, A., Mayer, D., Hafner, J & Sibbald, R. G. (2012). Martorell hypertensive ischemic leg ulcer: an underdiagnosed Entity. Adv Skin Wound Care, 25(12):563-72. Alexiadou, K & Doupis, J. (2012). Management of Diabetic Foot Ulcers. Management of Diabetic Foot Ulcers, 3 (1): 1-27. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508111/ Collins, L and Seraj, S. (2010). Diagnosis and Treatment of Venous Ulcers. American Family Physician, 15;81(8):989-996. Graham, I. D., Harrison, M. B., Shafey, M & Keast, D. (2003). Knowledge and attitudes regarding care of leg ulcers. Canadian Family Physician, 49: 896-902. Retrieved from http://www.cfp.ca/content/49/7/896.full.pdf Spentzouris, G & Labropoulos, N. (2009). The Evaluation of Lower-Extremity Ulcers. Seminars in Interventional Radiology, 26 (4): 286-295. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3036466/ Sukumar, A. (2000). General Surgery for BDS Students. India: Orient Blackswan. Retrieved from Google Books. Weller, C. D., Ademi, Z., Makarounas-Kirchmann K & Stoelwinder, J. (2012). Economic evaluation of compression therapy in venous leg ulcer randomised controlled trials: A systematic review. Wound Practice and Research. 20 (1): 21-34. Woelk, C. J. (2012). Management of critical limb ischemia. Canadian Family Physician, 58 (9): 960-963. Read More