Dermatologic Emergencies

dermatology-emergencieskapak-1-0-25

Venous Stasis and Diabetic/Neuropathic Ulcers

İsmail Erkan AYDIN
Alanya Alaaddin Keykubat University Faculty of Medicine, Department of Emergency Medicine, Antalya, Türkiye

Aydın İE. Venous stasis and diabetic/neuropathic ulcers. In: Oğuztürk H, Görmeli Kurt N, eds. Dermatologic Emergencies.  1st ed. Ankara: Türkiye Klinikleri; 2025. p.148-56.

ABSTRACT

Venous stasis is a pathology that occurs as a result of valve insufficiency, venous reflux or venous obstruction of the lower extremity veins. As a result of venous stasis, leg swelling, stasis dermatitis may occur and then more serious conditions such as venous ulcers may occur. Chronic venous insufficiency is the most common cause of venous stasis and ulcers. Being over 55 years of age, family history, obesity, history of pulmonary embolism, history of deep vein thrombosis, lower extremity bone or joint disease, pregnancy, and immobility are among the risk factors. It appears with venous disease symptoms such as varicose veins, edema or venous dermatitis. It is caused by inflammation in the subcutaneous fat tissue and causes thickening and hyperpigmentation in the levels above the ankle. Its differential diagnosis includes arterial ulcers, diabetic/neuropathic ulcers and pressure ulcers. Definitive treatment of venous stasis and ulcers is done by treating chronic venous insufficiency. Treatment of skin lesions with topical corticosteroids is used to reduce pain and swelling. It is possible to reduce venous hypertension with compression stockings and bandages. It may be possible to treat venous insufficiency with surgical treatment. Diabetic ulcers cause amputations and deaths in millions of people worldwide. Patient education, appropriate shoe selection, blood sugar regulation, peripheral arterial revascularization, broad-spectrum antibiotics, debridement and a multidisciplinary approach are important for the treatment of diabetic ulcers. Annual foot examinations should be performed in all diabetic patients. More frequent follow-up should be performed for patients with a history of diabetic ulcers. Identifying patients at high risk of ulcers and early referral for treatment when necessary are the most important steps.

Keywords: Diabetic foot; diabetic neuropathies; venous ulcer; venous insufficiency

Referanslar

  1. Yosipovitch G, Nedorost ST, Silverberg JI, Friedman AJ, canosa JM, cha A. Stasis Dermatitis: An Overview of Its clinical Presentation, Pathogenesis, and Management. Am J clin Dermatol. 2023;24(2):275-86. [Crossref]  [PubMed]  [PMC]
  2. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The Epidemiology of chronic Venous Insufficiency and Varicose Veins. Ann Epidemiol. 2005;15(3):175-84. [Crossref]  [PubMed]
  3. Bawakid KO, Al-Raddadi RM, Sabban SS, Alturky KA, Mohamed MS. Prevalence of chronic venous insufficiency in the Saudi adult population. Saudi Med J. 2005;26(2):225-9. [PubMed]
  4. White J V. chronic Venous Insufficiency. Perspect Vasc Surg Endovasc Ther. 2005;17(4):319-27. [PubMed]
  5. Yalçın b, Tamer E, Toy GG, Öztaş P, Hayran M, Allı N. The prevalence of skin diseases in the elderly: analysis of 4099 geriatric patients. Int J Dermatol. 2006; 45(6):672-6. [Crossref]  [PubMed]
  6. Milic DJ, Zivic SS, bogdanovic Dc, Golubovic MD, Lazarevic MV, Lazarevic KK. A randomized trial of class 2 and class 3 elastic compression in the prevention of recurrence of venous ulceration. J Vasc Surg Venous Lymphat Disord. 2018;6(6):717-23. [Crossref]  [PubMed]
  7. Sundaresan S, Migden MR, Silapunt S. Stasis Dermatitis: Pathophysiology, Evaluation, and Management. Am J clin Dermatol. 2017;18(3):383-90. [Crossref]  [PubMed]
  8. Fiebig A, Krusche P, Wolf A, Krawczak M, Timm b, Nikolaus S, et al. Heritability of chronic venous disease. Hum Genet. 2010;127(6):669-74. [Crossref]  [PubMed]  [PMC]
  9. Anwar MA, Georgiadis KA, Shalhoub J, Lim cS, Gohel MS, Davies AH. A Review of Familial, Genetic, and congenital Aspects of Primary Varicose Vein Disease. circ cardiovasc Genet. 2012;5(4):460-6. [Crossref]  [PubMed]
  10. Schmid-Schönbein GW, Takase S, bergan JJ. New Advances in the Understanding of the Pathophysiology of chronic Venous Insufficiency. Angiology. 2001;52(1_suppl):S27-34. [Crossref]  [PubMed]
  11. Comerota A, Lurie F. Pathogenesis of venous ulcer. Semin Vasc Surg. 2015;28(1):6-14. [Crossref]  [PubMed]
  12. Kügler c, Strunk M, Rudofsky G. Venous Pressure Dynamics of the Healthy Human Leg. J Vasc Res. 2001;38(1):20-9. [Crossref]  [PubMed]
  13. Moura RMF de, Gomes H de A, da Silva SLA, britto RR, Dias Rc. Analysis of the physical and functional parameters of older adults with chronic venous disease. Arch Gerontol Geriatr. 2012;55(3):696-701. [Crossref]  [PubMed]
  14. Lurie F, Passman M, Meisner M, Dalsing M, Masuda E, Welch H, et al. The 2020 update of the cEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord. 2020;8(3):342-52. [Crossref]  [PubMed]
  15. Bonkemeyer Millan S, Gan R, Townsend PE. Venous Ulcers: Diagnosis and Treatment. Am Fam Physician. 2019;100(5):298-305. [Link]
  16. Stevens DL, bryant AE. Streptococcus pyogenes Impetigo, Erysipelas, and cellulitis. 2022 Sep 7 [Updated 2022 Oct 4]. In: Ferretti JJ, Stevens DL, Fischetti VA, editors. Streptococcus pyogenes: basic biology to clinical Manifestations [Internet]. 2nd edition. Oklahoma city (OK): University of Oklahoma Health Sciences center; 2022 Oct 8. chapter 23. Available from: [Link]
  17. Palmer b, Xia Y, cho S, Lewis FS. Acroangiodermatitis secondary to chronic venous insufficiency. cutis. 2010;86(5):239-40. [PubMed]
  18. O'Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg. 2014;60(2):3S-59S. [Crossref]  [PubMed]
  19. Kokkosis AA, Labropoulos N, Gasparis AP. Investigation of venous ulcers. Semin Vasc Surg. 2015;28(1):15-20. [Crossref]  [PubMed]
  20. Vivas A, Lev-Tov H, Kirsner RS. Venous Leg Ulcers. Ann Intern Med. 2016;165(3):IT c 17. [Crossref]  [PubMed]
  21. Lal bK. Venous ulcers of the lower extremity: Definition, epidemiology, and economic and social burdens. Semin Vasc Surg. 2015;28(1):3-5. [Crossref]  [PubMed]
  22. Mosti G, Picerni P, Partsch H. compression stockings with moderate pressure are able to reduce chronic leg oedema. Phlebology: The Journal of Venous Disease. 2012;27(6):289-96. [Crossref]  [PubMed]
  23. Cullum N, Nelson E, Fletcher A, Sheldon T. compression for venous leg ulcers. In: cullum N, ed. The cochrane Database of Systematic Reviews. chichester, UK: John Wiley & Sons, Ltd; 2001. [Crossref]
  24. Paller AS, Tom WL, Lebwohl MG, blumenthal RL, boguniewicz M, call RS, et al. Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults. J Am Acad Dermatol. 2016;75(3):494-503.e6. [Crossref]  [PubMed]
  25. Aziz Z, Tang WL, chong NJ, Tho LY. A systematic review of the efficacy and tolerability of hydroxyethylrutosides for improvement of the signs and symptoms of chronic venous insufficiency. J clin Pharm Ther. 2015;40(2):177-85. [Crossref]  [PubMed]
  26. Gohel MS, Heatley F, Liu X, bradbury A, bulbulia R, cullum N, et al. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. N Engl J Med. 2018;378(22):2105-14. [Crossref]  [PubMed]
  27. Andriessen A, Apelqvist J, Mosti G, Partsch H, Gonska c, Abel M. compression therapy for venous leg ulcers: risk factors for adverse events and complications, contraindications - a review of present guidelines. J Eur Acad Dermatol Venereol. 2017;31(9):1562-8. [Crossref]  [PubMed]
  28. Jull Ab, Arroll b, Parag V, Waters J. Pentoxifylline for treating venous leg ulcers. cochrane Database of Systematic Reviews. 2012. [Crossref]  [PubMed]  [PMC]
  29. Jankunas V, bagdonas R, Samsanavicius D, Rimdeika R. An Analysis of the Effectiveness of Skin Grafting to Treat chronic Venous Leg Ulcers. Wounds. 2007;19(5):128-37. [PubMed]
  30. Armstrong DG, Tan TW, boulton AJM, bus SA. Diabetic Foot Ulcers. JAMA. 2023;330(1):62. [Crossref]  [PubMed]  [PMC]
  31. Zhang Y, Lazzarini PA, McPhail SM, van Netten JJ, Armstrong DG, Pacella RE. Global Disability burdens of Diabetes-Related Lower-Extremity complications in 1990 and 2016. Diabetes care. 2020;43(5):964-74. [Crossref]  [PubMed]
  32. Armstrong DG, boulton AJM, bus SA. Diabetic Foot Ulcers and Their Recurrence. N Engl J Med. 2017;376(24):2367-75. [Crossref]  [PubMed]
  33. Boulton AJM, Whitehouse RW. The Diabetic Foot. 2000. [Link]
  34. Reardon R, Simring D, Kim b, Mortensen J, Williams D, Leslie A. The diabetic foot ulcer. Aust J Gen Pract. 2020;49(5):250-5. [Crossref]  [PubMed]
  35. Sloan G, Selvarajah D, Tesfaye S. Pathogenesis, diagnosis and clinical management of diabetic sensorimotor peripheral neuropathy. Nat Rev Endocrinol. 2021;17(7):400-20. [Crossref]  [PubMed]
  36. Lam K, van Asten SAV, Nguyen T, La Fontaine J, Lavery LA. Diagnostic Accuracy of Probe to bone to Detect Osteomyelitis in the Diabetic Foot: A Systematic Review. clin Infect Dis. 2016;63(7):944-8. [Crossref]  [PubMed]
  37. Mills JL, conte MS, Armstrong DG, Pomposelli Fb, Schanzer A, Sidawy AN, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI). J Vasc Surg. 2014;59(1):220-34.e2. [Crossref]  [PubMed]
  38. van Reijen NS, Ponchant K, Ubbink DT, Koelemay MJW. Editor's choice - The Prognostic Value of the WIfI classification in Patients with chronic Limb Threatening Ischaemia: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surgy. 2019;58(3):362-71. [Crossref]  [PubMed]
  39. Aragón‐Sánchez J, Lipsky bA, Lázaro‐Martínez JL. Diagnosing diabetic foot osteomyelitis: is the combination of probe‐to‐bone test and plain radiography sufficient for high‐risk inpatients? Diabetic Medicine. 2011;28(2):191-4. [Crossref]  [PubMed]
  40. Lipsky bA, Senneville É, Abbas ZG, Aragón‐Sánchez J, Diggle M, Embil JM, et al. Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36(S1). [Crossref]  [PubMed]
  41. Fitridge R, chuter V, Mills J, Hinchliffe R, Azuma N, behrendt cA, et al. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. J Vasc Surg. 2023;78(5):1101-31. [Crossref]  [PubMed]
  42. Chen P, Vilorio Nc, Dhatariya K, Jeffcoate W, Lobmann R, McIntosh c, et al. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3). [Crossref]  [PubMed]
  43. Farber A, Menard MT, conte MS, Kaufman JA, Powell RJ, choudhry NK, et al. Surgery or Endovascular Therapy for chronic Limb-Threatening Ischemia. N Engl J Med. 2022;387(25):2305-16. [Link]