Stasis ulcer
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Synopsis
The primary pathophysiology involves incompetent one-way venous valves or dysfunctional calf muscle pumping, leading to insufficient venous blood return to the heart and chronic leg venous hypertension. This venous hypertension leads to aberrant tissue perfusion and subsequent decreased delivery of oxygen and nutrients, failure to remove metabolic byproducts, and tissue ischemia.
Additional clinical features commonly associated include leg and ankle edema, varicose veins, yellow-brown pigmentation secondary to hemosiderin deposition and extravasated red blood cells, eczematous changes with scaling and crusting (stasis dermatitis), and lymphedema. Lipodermatosclerosis is also seen and corresponds to fibrotic changes in subcutaneous tissue leading to a hard and indurated feel to the skin. An "inverted champagne bottle" leg indicates end stage lipodermatosclerosis and is caused by severe fibrotic changes in the distal leg and leg edema of the proximal leg. Atrophie blanche are smooth, ivory-colored atrophic plaques secondary to sclerosis seen in approximately 40% of patients with venous insufficiency.
Additional key points are that stasis ulcers usually begin on the medial malleolus but may become circumferential over time. They may be painful, are difficult to treat, and frequently recur. They may become secondarily infected.
Codes
ICD10CM:I83.009 – Varicose veins of unspecified lower extremity with ulcer of unspecified site
SNOMEDCT:
41915009 – Stasis ulcer
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Arterial ulcers – Weak or absent distal pulses, does not have surrounding areas of dermatitis, has a punched-out appearance; located anteriorly or laterally on the lower extremity consistent with pressure sites.
- Neurogenic (diabetic) ulcer – Almost invariably has peripheral neuropathy with decreased sensation and HgbA1C that is elevated; look for punched-out ulcers that are in pressure sites.
- Pyoderma gangrenosum – Look for very painful ulcers that have an irregular necrotic, undermined, overhanging border; these can occur anywhere.
- Thromboangiitis obliterans – Weak or absent distal pulses. Patients almost invariably have a history of smoking. Upper limb involvement is also seen.
- Cryofibrinogenemia – Look for associated livedo reticularis and purpura.
- Acroangiodermatitis – Although they do not often ulcerate, lesions are commonly seen in conjunction with venous hypertension and manifest as violaceous patches and plaques that appear on the extensor surfaces of the distal lower extremities.
- Martorell (hypertensive) ulcer
- Sickle cell ulcer
- Trauma
- Bullous impetigo
- Squamous cell carcinoma
- Atypical mycobacterium infection
- Panniculitis with ulceration
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Management Pearls
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Therapy
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References
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Last Reviewed:09/11/2018
Last Updated:02/12/2019
Last Updated:02/12/2019
Patient Information for Stasis ulcer
Overview
A stasis ulcer is a breakdown of the skin (ulcer) caused by fluid build-up in the skin from poor vein function (venous insufficiency). Fluid leaks from the veins into skin tissue when the blood backs up rather than returning to the heart through the veins.Who’s At Risk
Leg vein malfunction (venous insufficiency) affects 2-5% of Americans, and approximately half a million Americans have stasis ulcers. Women are more often affected by stasis ulcers than men.Your risk for acquiring a stasis ulcer is greater if you:
- Are overweight.
- Have varicose veins.
- Have had blood clots in your legs.
- Had a leg injury (trauma) that might affect blood flow in your leg veins; even minor trauma may cause an ulcer.
Signs & Symptoms
Swelling of the leg, brown discoloration, or an itchy, red, rough area (stasis dermatitis) may appear before you notice an ulcer. This is often seen on the inner ankle area first, although any area on the lower leg may be affected. Varicose veins may be present. Sometimes there are hard, tender lumps under the skin near the ulcer.The ulcer is a crater-like, irregular area of skin loss. It may be an open, easily bleeding, painful wound, or it might have a thick black scab. The level of pain varies.
Self-Care Guidelines
People with a leg ulcer should seek medical care if it is anything beyond a small scrape or cut on the surface of the skin.If the ulcer appears minor:
- Clean it with soap and water.
- Apply a thin layer of petroleum jelly (Vaseline) and a clean gauze bandage.
- Avoid putting any tape or adhesive on the skin.
- Avoid using topical antibiotics and other over-the-counter products, as people with leg ulcers often become allergic to these products.
When to Seek Medical Care
If you have pain, swelling, spreading red areas, fever, or any open wound that does not heal after a few days of self-care, seek medical advice.Treatments
In addition to a thorough exam, your physician may test to evaluate how well your veins are working.Treatment may consist of:
- Procedures to reduce leg swelling.
- Medication for any dermatitis or infection that is present.
- Special wound dressings.
- Pentoxifylline to aid healing.
- Surgery if other medical treatment fails.
- Compression hose to prevent the ulcer from coming back.
References
Bolognia, Jean L., ed. Dermatology, pp.1635. New York: Mosby, 2003.
Freedberg, Irwin M., ed. Fitzpatrick's Dermatology in General Medicine. 6th ed. pp.21. New York: McGraw-Hill, 2003.
Stasis ulcer