Chapter 53: Chronic Lower Extremity Ulcers Management and Evaluation

INTRODUCTION

Ulcers are defined as nonhealing, full-thickness wounds of different etiologies. In most cases, healing failure is related to underlying conditions such as diabetes, lower-extremity arterial or venous disease, or generalized patient health such as in malnutrition and impaired mobility. Skin ulcerations are a common condition that are increasing in prevalence, secondary to the aging population and an increase in chronic health problems. Lower extremity (LE) ulcers are described to be chronic if they do not show tendency to heal after 3 months of appropriate treatment or are still not fully healed at 12 months.¹ The impact of chronic skin ulcers is multifactorial and includes physical symptoms, intractable pain, loss of function, loss of work days, and social stress on the patient, family, and caregivers. There are also significant associated economic implications for the patient, family, and the healthcare system as whole.

Epidemiology

Chronic ulcers of the LEs are a common problem affecting about 1% to 2% of the adult population in the United States.¹ Treatment of these ulcers represents a major economic burden, with an annual cost of $23.9 to $27.9 billion.^2,3 Economic impact of chronic ulcers in the United States has been found to be much higher than is recognized based on Medicare data, as a good proportion of expenditure occurs in the outpatient setting. The total Medicare spending estimates in 2014 ranged from $28.1 to $96.8 billion.⁴

Because of differing etiologies and management, LE ulcers are divided into ulcers that affect the legs and ulcers that affect the feet. Leg ulcerations are generally secondary to venous disease or atypical causes, while ulcers on the feet are typically secondary to neuropathy and arterial disease.⁵ LE venous disease accounts for more than 70% of leg ulcers, while about 85% of foot ulcers are caused by peripheral neuropathy and commonly associated with peripheral arterial occlusive disease. Presence of neuropathy results in modifying the symptoms that might result from peripheral arterial occlusive disease.⁶ In a study of the 2014 Medicare population, the prevalence of wounds of all types increased with age, with surgical wounds being of highest prevalence (4%), followed by diabetic foot infections (3.4%). Among chronic ulcers, the most common type identified in this study were pressure ulcers (1.8%), venous ulcers (0.9%), diabetic foot ulcers (0.7%), and arterial ulcers (0.4%) (Table 53-1).⁴