Introduction

Vascular ulcers are wounds on the skin that form as the result of abnormal blood circulation in the body, including arterial and venous etiologies.¹ Estimates suggest 3-5% of those over 65 in the United States have a vascular ulcer.¹ Of those with peripheral arterial disease, approximately 20-70% have chronic wounds, according to data up to 2018.² Since arterial ulcers may be underdiagnosed, certain experts theorize that the number of chronic wounds developed due to arterial insufficiency is higher in reality.² Clinicians must differentiate between arterial and venous ulcers, as they require distinctly different treatments that may prove detrimental if used to treat the other condition. Therefore, wound care professionals should familiarize themselves with the varying characteristics of all types of vascular wounds.

What Are Venous and Arterial Ulcers?

Arterial ulcers are skin injuries that develop due to tissue ischemia. Ischemia develops when there is insufficient blood perfusion to the extremities due to problems in arterial circulation. As a result, blood cells cannot deliver the necessary nutrients and oxygen to tissues, creating a higher risk for necrosis and open wounds.³ Venous ulcers occur when there is damage or a break in the leg's skin in a person with impaired venous valves. These leg valves struggle to return blood to the heart, often resulting in fluid buildup in the lower extremities. If swelling/edema is significant, it can cause pain and fluid leakage through the skin.⁴

Risk Factors

Multiple factors can contribute to the development of an arterial wound. The most common cause is atherosclerosis, and, therefore, the following are risk factors for atherosclerosis which may lead to arterial ulcers³:

• Smoking
• Hypertension
• Dyslipidemia
• Diabetes
• Family history

One should note that arterial insufficiency often does not act alone in causing arterial ulcers. Other contributing forces, such as trauma or neuropathy, often play a role.³ Venous ulcers occur when blood pools in the veins, causing an increase in pressure and can be caused by a variety of conditions. Risk factors include any disease that impacts the veins, including the following⁵:

• Varicose veins
• Phlebitis or Deep Vein Thrombosis (DVT)
• Traumatic or past injury to the lower extremities

While not all these factors can be prevented, clinicians can recommend measures to reduce patient risk of vascular damage. These recommendations may include increasing activity, avoiding smoking, maintaining a healthy weight, reducing stress levels, and keeping blood sugars stable.⁶

What Are the Characteristics of Arterial Ulcers?

Clinicians often find arterial ulcers on pressure points of the foot, such as the tips of the toes and the ankles. They are usually found in these distal areas because they are the furthest distance away from the heart.¹ If a patient develops an injury on their foot, it may also develop into an arterial ulcer. Assessment of the lower extremities will likely show the skin to be shiny, dry, thin, and taut with sparse or no hair and be cool to the touch.^7,8 Pedal pulses may also be decreased or absent.⁷ Arterial ulcers appear “punched-out” and can appear round with clearly defined wound margins.^6,7 They tend to be dark in color and may present as yellow, gray, brown, or black with hints of pink or red. These wounds are often rather deep, and new tissue growth is not usually readily evident. Typically, the bases of these wounds won’t bleed.⁷

Due to ischemia, these wounds are prone to infection because the body's defenses cannot be delivered through the blood to the tissues effectively.¹ These ulcers can be very painful, and pain may occur with moderate to heavy activity. This type of pain is known as claudication, which can also worsen with lower extremity elevation.⁸ Nighttime pain can be a problem if patients lay flat in bed at night because, with the legs in a horizontal position, cardiac output is decreased, and the lack of blood flow to the legs increases pain.⁶ To properly identify arterial insufficiency, wound care professionals should first provide the patient with a referral to a vascular specialist from the multidisciplinary team. The involvement of a vascular specialist will likely result in measurements such as the patient’s ankle-brachial index (ABI), toe-brachial index (TBI), transcutaneous oxygen levels, Doppler studies, or more advanced studies.⁷

What Are the Characteristics of Venous Ulcers?

Venous ulcers are generally found on the lower extremities between the ankles and knees, known as the gaiter area, and the medial malleolus. These wounds are shallow and ruddy with an irregular shape. The presence of slough or exposed subcutaneous tissue can also give wounds a yellow color, and exudate may be moderate to severe. The skin on the patient’s lower extremities may be thick and flaky with scabs and may itch or burn. Skin can become discolored and remain red, purple, maroon, or brown, even once ulcers have healed.⁵ Edema is a hallmark of venous insufficiency, and venous ulcer pain tends to be related more to the edema than wounds alone.⁶ Pain is generally dull and aching and improves with elevation.⁵

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Treatment

To heal an arterial ulcer, clinicians should improve circulation. To accomplish this, there are various endovascular and open procedures for revascularization in the right candidates after full evaluation of the level and e. Experts have found other therapeutic interventions, such as structured exercise therapy (SET), increase mobility and reduce pain at rest due to arterial insufficiency.² Amputation may be necessary if the damage to the vessels is extensive.¹ Infections may need to be treated with antimicrobial dressings, cleaning solutions, and possibly oral or IV medications. Avoiding excess pressure or shear to the limbs in both arterial and venous ulcers is essential.

Conversely, compression and elevation are ideal therapy options for venous ulcers. Compression wraps or stockings help the vessels return fluid to the heart. Clinicians should elevate patients' legs so that gravity can aid in pulling blood down. It may take several months or even years for venous ulcers to heal, depending on the patient's ability to tolerate compression dressings and elevation. Absorbent dressings that are easy to remove will help control exudate and prevent tissue damage upon removal. Wound care professionals should continue these tactics to prevent wounds from returning even after the ulcers have healed.⁴

Conclusion

Although there is some crossover in risk factors for and presentation of arterial and venous ulcers, each has key features that will assist the clinician in their differentiation. A careful history and physical exam will identify essential clues to the ulcer's etiology. The ulcer's appearance, coloration, and depth, along with the condition and characteristics of the surrounding skin and tissue, are vital pieces of information. Additionally, a focused pain assessment, including aggravating and alleviating factors, will help distinguish the type of ulcer in question and hopefully lead to a clearer pathway for diagnosis and treatment.

References

1. Vascular Ulcer. Cleveland Clinic. Accessed January 18, 2023. https://my.clevelandclinic.org/health/diseases/23357-stasis-ulcer.
2. Bolton L. Peripheral arterial disease: Scoping review of patient-centered outcomes. Inter Wound J. 2019;16:1521-1532. https://doi.org/10.1111/iwj.13232
3. Hess CT. Arterial Ulcer Checklist. Adv Skin Wound Care. 2010;23(9):432. Doi: 10.1097/01.ASW.0000383218.26406.4b
4. Venous Ulcers - Self-Care: Medlineplus Medical Encyclopedia. MedlinePlus. Accessed January 19, 2023. https://medlineplus.gov/ency/patientinstructions/000744.htm.
5. Bonkemeyer Millan S, Gan R, Townsend PE. Venous Ulcers: Diagnosis and Treatment. Am Fam Physician. 2019;100(5):298-305.
6. Bryant RA, Nix DP. Acute & Chronic Wounds: Current Management Concepts. 5th ed. St. Louis, MO: Mosby;2015.
7. Arterial Ulcers. WoundSource. Accessed February 1, 2023. https://www.woundsource.com/patientcondition/arterial-ulcers
8. Eriksson E, Liu PY, Schultz GS, et al. Chronic wounds: Treatment consensus. J Wound Repair and Regeneration. 2022;30:156-171. https://doi.org/10.1111/wrr.12994