Definition
A.Vascular ulcer:
1.Arterial/ischemic ulcer:
a.Skin ulcers usually found from the toes to the ankle region; ulcers fail to heal due to inadequate arterial flow.
2.Venous ulcer:
a.Chronic skin and subcutaneous lesions are usually found on lower extremity between the ankle and knee, thought to occur from intracellular edema or inflammatory processes.
B.Diabetic foot ulcer:
1.Skin ulcers usually found on the plantar surface of the foot, most commonly occurring from trauma or plantar pressure.
Incidence
A.Diabetic foot ulcers precede over 80% of lower extremity amputations in the United States.
B.The financial burden of venous ulcers is estimated to be $2 billion per year in the United States.
C.Up to 20% of lower extremity ulcers have been shown to have mixed etiology disease.
Pathogenesis
A.An ulcer that is found between the knees and toes constitutes a lower extremity ulcer, and guidelines are based according to the etiology. The thing to remember with lower extremity ulcers is that they often may have more than one cause. The most common etiologies are venous insufficiency, arterial insufficiency, diabetic foot ulcer, and/or pressure.
Predisposing Factors
A.Arterial insufficiency.
B.Congestive heart failure.
C.Coronary heart disease.
D.Diabetes.
E.Edema.
F.Hyperlipidemia.
G.Obesity.
H.Age: Older than 65 years.
I.Venous insufficiency.
J.Peripheral neuropathy.
Common Complaints
A.Lower extremity or foot pain.
B.Bleeding.
C.Drainage.
D.Hyperglycemia.
Subjective Data
A.Ask the patient to describe the location and onset. What does he or she think may have caused an ulcer in that area? Was the onset sudden or gradual? How have the symptoms continued to develop?
B.Assess if the area is pruritic or painful. Does the patient have feeling in the area or is there a decrease in sensation noted?
C.Assess for any associated drainage. Ask about the color and if any odor is present.
D.Complete a drug history. Ask the patient if he or she is taking any steroids or anticoagulants.
E.Has the patient been treated for this location in the past? If so, describe?
F.Determine whether the patient has attempted to treat this at home. If yes, inquire about previous treatments.
G.Does the patient have any numbness or tingling in the lower extremities? Does the patient wake up at night with pain? Does he or she have any pain with ambulation? Does he or she have sensation to his or her feet?
H.Rule out any possible exposure to industrial or domestic toxins, or insect bites.
I.Assess for iodine and sulfa allergies before starting treatment.
Physical Exam
A.Check temperature, pulse, respirations, and blood pressure.
B.Assess the lower extremities, feet, and toes:
1.Color of the skin:
a.Assess skin, beginning at the top of the legs; move down the legs to the toes for changes in color that may exhibit signs of ischemia.
b.Hemosiderin staining may exhibit venous insufficiency.
2.Temperature of the skin.
3.Sensation of the skin.
4.Capillary refill.
5.Pulses.
C.Inspect the ulcer:
1.Measure length × width × depth:
a.Undermining (destroyed tissue below the wound margin): Measure and note location, using the face of a clock to document the site of undermining: for example, 12 o’clock, 3 o’clock, 6 o’clock, or 9 o’clock.
b.Tunneling (destroyed tissue pathway that creates dead space underneath the skin): Measure and note location, using the face of a clock to document the site of tunneling: for example, 12 o’clock, 3 o’clock, 6 o’clock, or 9 o’clock.
2.Describe the wound bed:
a.Tissue in the wound bed:
i.Necrotic tissue, slough tissue, granulation tissue, epithelial tissue (percentage of each should together equal 100%).
b.Drainage:
i.Amount:
•None, scant, moderate, copious.
ii.Color:
•Serous, purulent, yellow, serosanguineous, green.
c.Odor:
i.Odor present: Yes.
ii.Odor not present: No.
d.Periwound:
i.Intact.
ii.Not intact:
•Describe periwound. Note erythema, fever, induration, maceration, excoriation, calloused area, or epiboly.
Diagnostic Tests
A.Ankle brachial index (ABI).
B.Arterial Doppler.
C.Bone scan.
D.Complete blood count (CBC).
E.Hemoglobin A1C (HgbA1c) .
F.MRI.
G.Wound culture.
H.Wound biopsy.
I.Venous Doppler.
J.X-ray.
Differential Diagnoses
A.Vascular ulcer:
1.Arterial/ischemic ulcer.
2.Venous ulcer.
B.Diabetic foot ulcer.
C.Abscess.
D.Atypical ulcers.
E.Dermatological disorder.
F.Necrotizing fasciitis.
G.Skin cancers.
H.Pressure ulcer.
I.Trauma.
J.Pyoderma gangrenosum.
Plan
A.Vascular ulcers:
1.Arterial ulcer:
a.Refer to vascular surgery for assessment to improve arterial flow.
b.Refer to wound care specialist.
2.Venous ulcer:
a.Establish arterial flow:
i.Refer to vascular surgeon if deficiency found.
b.For signs and symptoms of infection, treat the infection first with tissue culture and sensitivity. Treat per pharmaceutical recommendations. Treat with silver alginate to the site for moderate drainage and silver gel to the site for scant drainage.
c.Once arterial flow has been established as sufficient and infection has been ruled out, compression therapy is the mainstay of treatment for venous ulcers. Compression therapy recommendations:
i.ABI: 0.8 to 1.0 full compression:
•Profore.
•Apply calcium alginate to ulcer, then wrap with an Unna Boot and cover with a coban wrap:
–Change in 3 days; if tolerating well, then change weekly.
ii.ABI: 0.6 to 0.8 light compression:
•Profore Lite.
•Apply calcium alginate to ulcer, then wrap with an Unna Boot and cover with a coban wrap:
–Change in 3 days; if tolerating well, then change weekly.
B.Diabetic foot ulcer:
1.Establish arterial flow.
a.Refer to vascular surgeon if deficiency is found.
2.For signs and symptoms of infection, use a sterile culturette to obtain a tissue culture and sensitivity first to assess what organism is present and to determine sensitivities. Treat per pharmaceutical recommendations. Treat with silver alginate to the site for moderate drainage and silver gel to the site for scant drainage.
3.Initiate offloading to site:
a.Refer to orthotist for assessment if devices are required:
4.Treatment options:
a.To debride: Normal saline (NS) cleanse, apply santyl and dressing change daily and as needed.
b.To granulate an ulcer with scant drainage: NS cleanse, apply hydrogel and dressing; change daily as needed.
c.To granulate an ulcer with moderate drainage: NS cleanse, apply calcium alginate and dressing change daily and as needed.
C. 
See Section III: Patient Teaching Guide Wound Care: Lower Extremity Ulcers.
D.Pharmaceutical therapy:
1.If culture and sensitivity are performed, antibiotics may be used as recommended per sensitivity.
Follow-Up
A.Follow up in 1 to 2 weeks to evaluate therapy.
B.See patients every 1 to 2 weeks until healing well; then may reduce to 2- to 4-week evaluation until complete closure.
Consultation/Referral
A.Consult or refer the patient to a wound care specialist:
1.Patient has extensive ulcer that you are not comfortable with:
a.Visible bone, muscle, or tendon.
2.Patient has multiple medical comorbidities (especially diabetes).
3.Patient is not responding to treatment of 2 to 4 weeks.
4.Ulcer is showing decrease on follow-up visit.
5.Infection is present.
Individual Considerations
A.Adults:
1.Ischemic ulcers warrant immediate referral.
2.Complaints of severe pain, lack of pulse, cool digit, or new onset of purplish/bluish discolorations to the feet require immediate workup for arterial clot to lower extremity.