@ Skin Condition

LEG ULCERS & PRESSURE ULCERS

Leg ulceration is a chronic disease occurring predominantly in the older population. An ulcer can be defined as a local deficit or excavation of the surface of an organ or tissue, which is produced by the sloughing of inflammatory necrotic tissue. Ulcers may be present for many years but can be successfully treated following a comprehensive medical assessment, appropriate clinical management and patient compliance to treatment. Estimates of prevalence range from 1.5 to 1.8 per 1000 total population, rising to 3 per 1000 at age 61-70 and to 20 per 1000 in people aged 80 and over. The annual cost to the National Health Service (NHS) is estimated to be in the region of £300-600 million. The majority of patients are cared for bycommunity services.

Venous ulcers account for 70-90% of all cases. Arterial ulcers account for 5- 20% of cases. Combined venous hypertension and arterial disease account for 10-15% of cases. Less common causes account for 5-10% of cases and include: diabetes, vasculitis, neoplasm, infection and trauma and other less specific causes.

Causes and Symptoms
Venous ulceration can result from chronic venous hypertension in the lower limb, usually due to malfunctioning valves in the leg veins, of either congenital or acquired origin, resulting in a backflow of blood. The superficial venous network is exposed to higher pressures than normal resulting in oedema, capillary damage and thinning of the dermis (inner layer of the skin containing vessels, nerves and fibrous tissue - covered by the epidermis). The subsequent leakage of red blood cells and large protein molecules creates the physiological conditions which can lead to ulcer formation. Varicosities (abnormal swelling of veins) are commonly present. Often the lower limb is swollen with a brown discoloration of the skin and the presence of an irritating eczema.

Arterial ulcers result from a reduced arterial circulation. Common causes include atherosclerotic changes in the main vessels and small emboli (blockages), not uncommonly the result of hypertension. Smoking and poor diet are contributory factors. The lower limb may appear pale or a dusky red colour and the patient commonly complains of pain, particularly when the limb is elevated or during exercise.

Leg ulceration impacts on the quality of daily life through pain, physical restrictions, sleep disturbance, reduced energy, emotional reactions and social isolation.

Treatments
Venous ulceration - treatment aims to counteract the high pressure in the superficial veins, increase the calf muscle pump mechanism to assist venous return and reduce oedema. This is achieved by applying graduated compression from the toes to the knee. Local wound management aims to achieve optimum healing conditions and avoid the exacerbation of varicose eczema. Underlying nutritional deficiencies should be corrected. The prognosis is good, providing the cause of the ulcer has been correctly assessed and management decisions have involved patient consultation. Support or compression hosiery is often necessary to prevent recurrence following healing.

Arterial ulceration - treatment includes the local management of the wound and avoids compression, which would exacerbate the arterial insufficiency. Vasodilator drugs may be used. The prognosis is poor, unless surgical intervention is possible to correct the arterial problems. Cessation of smoking, weight control, a nutritious diet and maintaining mobility are beneficial.

PRESSURE ULCERS

A pressure ulcer is an area of damaged skin and tissue caused by unrelieved pressure, shear or friction, typically sustained during long periods of bed or chair rest during illness or disability. Prevalence rates are estimated at between 7% and 10% in hospital and community patients. It is suggested to be costing the NHS in excess of £400 million per year. Treatment is aimed towards prevention, including relief of the pressure and avoidance of friction and shear forces. There are many pressure relieving aids available and methods of care aimed at prevention. Damaged skin should be covered with a suitable dressing.

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