Arterial ulcers

1 - ACKNOWLEDGEMENTS

Chapter written with the help of the EADV, the Fondation René Touraine and the Therapeutics in Dermatology

2 - OVERVIEW

Vascular ulcers are a serious health problem with high incidence and with important socioeconomic and health repercussions due to their long evolution and reduction of the quality of life of the patient. In general, it is estimated that between 1-2% of the European population has this chronic pathology.

Vascular ulcer is defined as an elementary injury with loss of cutaneous substance produced by deficiencies in sanguineous circulation which usually affects the lower extremities. The depth can range from the involvement of the most superficial layers of the skin to muscle and bone.

According to the etiology, vascular ulcers can be classified as venous, arterial and mixed.

Arterial ulcers are those in whose origin there is a deficiency of blood supply in the affected limb. They are also known as ischemic ulcers and represent 10-25% of all vascular ulcers.

3 - SIGNS AND SYMPTOMS

Signs that accompany arterial ulcers:

• Decreased temperature of the affected limb.
• Bright and dry skin.
• Alteration in the morphology or color of the nails.
• Atrophied limb (decrease in muscle size and loss of muscle strength).
• Absence of hair.
• Localization: fingers and external face of the leg (unlike the venous ones that are mainly in the internal face).
• Absence of edema/swelling (more characteristic of venous ulcers).

The main symptoms that we find accompanying the arterial ulcers might be:

• Acute and lacerating pain that appears at rest and increase with activity, at night or with compression.
• Feeling of coldness in the legs and feet as well as a decrease in thermal sensitivity.
• Functional impotence/weakness or inability associated with exercise (called intermittent claudication).

4 - WHO GETS IT AND CAUSES

Arterial ulcers usually appear in men older than 50 years. In women, they appear at ages over 65, although this trend is beginning to change as a result of smoking.

There are several risk factors that can influence the appearance of an arterial ulcer, such as:

• Tobacco.
• Diabetes Mellitus.
• Dyslipidemia
• Arterial hypertension.
• Consumption of alcohol.
• Little or no exercise

Ischemic ulcer is due in 90% of cases to atheromatous arteriosclerosis or chronic obstructive arteriosclerosis, which in turn is the main cause of peripheral arteriopathy of the lower limbs. This condition is characterized by narrowing and hardening of the arteries that carry blood to the feet and legs, resulting in decreased blood flow.

These ulcers cause an acute and stinging pain. In general, they are unilateral, have a flat shape and variable size and are accompanied by ischemia in the foot. The limb presents pale skin, thin, shiny, dry, without hair and thickened nails. Also, the absence of pulses in the lower extremities is characteristic.

Another cause is the vasculitic ulcer that has as its underlying disease the thromboangiitis obliterans or Buerger’s disease, an inflammatory vasculopathy that is closely linked to smoking and appears preferentially in men between 30 and 40 years old. It is extremely painful and presents successive outbreaks in the course of life. There is absence of distal pulses (conserving popliteal pulse).

The hypertensive ulcer or Martorell’s ulcer has a long-lasting diastolic hypertension as a base disease. They are rare, painful, bilateral, and wide with irregular and hyperemic borders. They are usually located on the antero-external face of the lower third of the leg and have difficult scarring.

5 - DIAGNOSIS AND TREATMENT

In order to arrive to diagnosis the first and most important approach will be a complete medical history and physical examination. Both extremities should be inspected for ulcers, gangrene, edema and atrophy as well as more specific alterations of peripheral arterial disease such as thinning of the nails, absence of hair growth, dry skin and cold temperature of the limb.

Pulses should be palpated (femoral, popliteal, posterior tibial and pedal), as well as auscultate possible murmurs, since this might help to determine the level of the lesion.

The most used non-invasive complementary tests are the ankle-brachial index, arterial Doppler ultrasound and photoplethysmography. Among the invasive tests, the most used are arteriography, AngioTC and AngioMRI.

A general laboratory analysis may be necessary to control cardiovascular risk factors, or tissue microbiological culture in case of suspected infection of an ulcer.

As a first treatment measure, the risk factors should be eliminated: abstinence from smoking, control of arterial hypertension and hyperlipidemia.

The indication of surgical treatment will depend on the clinical situation of the patient and the vascular territory that needs reconstruction. Patients who undergo surgery must maintain indefinite antiplatelet therapy (to prevent the formation of clots), and this should be initiated preoperatively.

In certain cases it will be necessary to perform a resection or amputation of non-viable areas when there is tissue necrosis established or when revascularization has not been possible.

The follow-up of patients with arterial injuries should be individualized. Before setting the frequency of cure of arterial ulcers, it is necessary to assess the affected person and record in their clinical history the factors that can influence the healing process, risk factors of new ulcers, nutritional factors, and signs and symptoms of the ulcer through the physical examination. It is also necessary to assess the personal and family environment, especially in terms of attitudes, skills and knowledge about the health problem.

In addition, during the care of the lesion, it is important to control the causal factors and local barriers that prevent healing, such as: elimination of devitalized tissue, control of bacterial load, control of exudate and stimulation of the edges.

6 - TIPS FOR MANAGING

The prevention of recurrence of arterial ulcers depends entirely on the possibilities of revascularization (restore blood flow) and strict control of cardiovascular factors.

Some recommendations to prevent and manage the appearance of arterial ulcers are the following:

• Suppression of smoking.
• Avoid tight clothes and wear comfortable shoes, if possible not open.
• Take care of the nails meticulously, avoid traumatisms in the feet and do not expose them to excessive temperatures. Keep feet clean and dry.
• Promote self-care and protect the skin to prevent infections.
• Practice daily exercise on regular basis. However, exercise will be contraindicated if there is a significant cardiorespiratory disorder or signs of severe ischemia.
• Continuous inspection of the feet to avoid the appearance of injuries and, where appropriate, early detection and intervention.
• Follow a balanced diet and, if necessary, increase the intake of protein and vitamin C.