Leg ulcers (UJ) are of venous origin in half of the cases, arterial in 13 to 25%, mixed in 11 to 15% and linked to another cause in 10 to 25%.
Presence of an ischemic component?
The first of the questions to be asked when faced with a non-healing UJ is the existence of an ischemic component. Certain parameters should raise suspicion, in particular the presence of cardiovascular risk factors, other atherosclerotic lesions or signs suggestive of arterial disease of the lower limbs (PAD). The demonstration of palpable peripheral pulses makes it possible to exclude such a hypothesis.
Otherwise, several examinations may be carried out. The measurement of the systolic pressure index (BPI), a simple examination that can be done with a pocket Doppler or during arterial echo-Doppler, is indicated in any patient with an abolition of peripheral pulses, functional signs of ‘AOMI, or an IPS < 0,8 ou > 1.3. The transcutaneous measurement of the oxygen pressure, a non-invasive examination accessible in certain centers, also has a prognostic value.
Is there an infection?
The presence of frank erysipelas (febrile perilesional inflammatory plaque), an abscess or frank suppuration at the level of the wound is very suggestive of an infection. But its early diagnosis is not always easy, in the face of non-specific inflammatory signs.
Worsening of the ulcer despite appropriate compression treatment, increased pain at or around the ulcer are warning signs. It is important to explore the wound with a stylet. Bone contact indicates osteitis. No additional examination should delay the start of antibiotic treatment: amoxicillin 50 mg/kg/day for 7 days or pristinamycin 1 g three times a day for 7 days. Deep bacteriological samples (needle punctures-aspirations) are recommended in the presence of bubbles.
Is the venous compression well conducted?
Venous compression is the etiological treatment of UJ with a venous component, which is the case for the majority.
“In first intention, in UJ of strictly venous cause (palpable pulse and/or IPS > 0.8), it is recommended to use multilayer compression systems (type Urgo K2, Coban 2)says Dr. Patricia Senet (Paris). There is no place in first intention for simple elastic bandages of the Biflex type, which are nevertheless widely prescribed in France. » In UJ of mixed origin (IPS between 0.6 and 0.8), compression by Comprilan or Rosidal K type inelastic bands is appropriate.
The underlying skin must be protected by a cotton tubular system or a standard cotton or Velpeau bandage.
Is there another etiology involved?
Not all leg ulcers are of vascular origin. Faced with a UJ that does not heal despite treatment that seems appropriate, another etiology must be sought, such as necrotic angiodermatitis, which would be involved in 10% of these cases. It is a necrotic wound, extensive and superficial, linked to arteriosclerosis of the vessels of the dermis, due to arterial hypertension or diabetes.
It is also necessary to eliminate an ulcerated cancer, which would represent 10% of UJ not healing. Skin biopsies must therefore be systematically performed in the absence of improvement following three to six months of well-conducted treatment or in the event of clinical suspicion of skin cancer (abnormal bud, bleeding) or of another etiology (vasculitis, Pyoderma gangrenosum).
Exergue: “There is no place in first intention for simple elastic bandages of the Biflex type, which are nevertheless widely prescribed in France”
Communication by Drs Patricia Senet (Paris) and Marc Bayen (Guesnain)
