Venous ulcers pose a worldwide problem that comes with high recurrence rates, risk of infection, and substantial costs to treat. Health care professionals must be knowledgeable about underlying causes and pathological features. The comorbidities that are often associated with venous ulcers contribute to these lesions and prolong healing times, which in return can cause further complications. Venous disease and venous hypertension are lifelong conditions requiring lifelong management. The vicious cycle of venous reflux and obstruction associated with chronic venous disease leads to ulceration(s). Management of venous ulcers requires comprehensive wound care and compression therapy for life.

Comorbidities Affecting Venous Leg Ulcers

Diabetes and Neuropathy

Diabetes is an insidious disease that targets the smallest arteries and nerves and as well as those located farthest from the heart. That's why individuals with diabetes often have a loss of sensation, called diabetic neuropathy, in their toes and feet. This means they may not be able to feel a developing blister, infection, or surgical wound problem.

Patients with diabetes have slower-healing wounds, which can lead to wound chronicity. Add uncontrolled glucose levels, and complications such as peripheral neuropathy and peripheral arterial disease become more likely. Neuropathy develops from poorly controlled glucose levels and leads to a loss of sensation. This increases the risks of trauma-type wounds, poor healing, infection, amputation, and death. Uncontrolled glycemic levels alter white blood cell function and increase the risk of infection. Patients with diabetes should be educated on focused blood sugar control to promote wound healing.¹

Peripheral Arterial Disease, Cardiopulmonary Disease, Chronic Obstructive Pulmonary Disease, and Sleep Disorders

These conditions all affect blood flow, cellular oxygen delivery, and carbon dioxide removal. The vascular system must be functioning adequately to transport oxygenated nutrients to the tissues. With insufficient perfusion or a hypoxic state, the tissue begins to fail, and a wound will develop. Peripheral arterial disease can be limb- and life-threatening. Minor cuts and scrapes can become a disaster for a patient with poor arterial flow. Determining the perfusion status is the primary focus for patients with an arterial ulcer. For healing potential, there must be adequate perfusion or improving perfusion. Healing is directly correlated with the ability to provide enough oxygen and nutrients to support the repair and healing process.²

Other Factors Contributing to Venous Leg Ulcers

There are other factors that contribute to developing a venous leg ulcer. Clinicians should perform a complete and thorough assessment to consider these factors during treatment planning and goal setting. Many medical conditions can divert the normal wound healing process, and they must be managed parallel to wound management.

Immune System Deficiency

The immune system is the body's natural defense mechanism against infection. Some conditions such as lupus can have a significant impact on the body's ability to fight infection. Immune deficiencies affect the inflammation, proliferative, and maturation phases of wound healing.

Age

During the aging process, skin becomes more fragile, and the risk of infection rises in response to the impeding inflammatory response. The older population tends to develop chronic diseases that impair circulation and tissue perfusion. Moisturize and check skin daily to provide consistency in monitoring for skin impairments.

Dementia, Depression, and Cognitive and Behavioral Health Issues

Dementia, depression, and behavioral and cognitive issues can decrease patients' ability to communicate or comply with their own healing plan of care. Major depression and anxiety can cause patients to become non-adherent with daily hygiene and dressing changes or to miss their wound care clinic visits.

Poor Nutritional Intake

Malnutrition or poor nutritional intake can slow or stall wound healing. The body works extra hard during wound healing and needs up to three times the normal daily requirements of protein and calorie intake. Intake of carbohydrates and of vitamins A, C, and E, zinc, iron, copper, and manganese is also very important in healing.²

Conclusion

There is a long list of medical conditions that can be precursors to or exacerbate the presence and/or development of venous leg ulcers. Thorough assessments, education, best practices, and a multidisciplinary approach are most effective for achieving good outcomes. Venous ulcer management should encompass a holistic approach taking into account risk factors and comorbidities.

References

1. Dangwal S, Stratmann B, Bang C, et al. Impairment of wound healing in patients with type 2 diabetes mellitus influences circulating micro RNA patterns via inflammatory cytokines. Arterioscler Thromb Vasc Biol. 2015;35(6):1480-1488. doi: 10.1161/ATVBAHA.114.305048. Available at: https://insights.ovid.com/arteriosclerosis-thrombosis-vascular-biology/… Accessed January 3, 2020.

2. Gulati A, Garcia L, Acharji S. Epidemiology of chronic critical limb ischemia. In: Dieter R, Dieter RA, Nnjundappa A, eds. Critical Limb Ischemia Acute and Chronic. Basel, Switzerland: Springer; 2017:671. https://link.springer.com/chapter/10.1007/978-3-319-31991-9_2#citeas. Accessed January 3, 2020.

3. Ruben B. 11 comorbidities that inhibit wound healing. WoundSource. 2014. https://www.woundsource.com/blog/11-comorbidities-inhibit-wound-healing. Accessed January 12, 2020.