Wound won’t heal? Could be venous insufficiency

Thick, discolored or inflamed skin and wounds that won’t heal are visible signs of advanced, treatable venous insufficiency.

Recently a local stage performer in Lehigh Acres was taken aback by the large pool of blood that had formed at his feet.

The patient had been taking care of his critically ill wife for years and been neglecting the open wound on his leg, an injury he had on and off for nearly five years. The patient had recounted, “It’s been about four or five years I’ve been fighting this. I have diabetes. I got a sore on my leg and it escalated. No matter what I did with it, it would always come back. The more I walked on it, the worse it would get.”

The musician’s physician began to suspect that there was more involved in his case than diabetes and referred him to Vein Specialists for further evaluation and treatment of his leg disorder. Based on the classic thickened and brownish discolored appearance of the leg it was apparent almost immediately that the leg ulcer and history of bleeding was secondary to venous insufficiency. Ultrasound confirmed great saphenous vein insufficiency and within four weeks of having the vein sealed with endovenous radiofrequency ablation, the ulcer was healed.

Veins are blood vessels that are specially designed to pump blood back toward the heart, against the force of gravity. Inside the veins are a series of one-way valves that open and close with the rhythm of muscle contractions. Healthy valves close tightly, keeping blood moving upward toward the heart. With vein disease or venous insufficiency, the valves do not close properly, causing pooling of blood in the leg veins, which leads to myriad signs and symptoms.

The discoloration and itching that occur is called stasis dermatitis, a result of the fluid and blood cells leaking out of the diseased veins into the skin and nearby tissues. Stasis dermatitis is a common sign as well as a complication of venous insufficiency which may be wrongly attributed to other diseases, including diabetes. This skin condition puts patients at significantly higher risk for developing venous ulcers as a result of minor trauma.

Stasis means pooling, static, not moving; derma means skin; and itis means inflammation. Stasis dermatitis is inflammation of the skin of the leg caused by blood pooling in the veins — in other words, by venous insufficiency. Another term often used to describe these abnormal skin changes is lipodermatosclerosis (Lipo=fat, dermato=skin and sclerosis= scar.

Venous insufficiency has many signs and symptoms other than the commonly recognizable varicose veins. These include achy legs, swollen legs and skin discoloration and ulceration.

With stasis pigmentation, the red blood cells, which contain pigment, leak out and break open, causing the discoloration. Then, the white blood cells leak out, and within the white cells are enzymes that are toxic to bacteria. But while the enzymes damage the bacterial walls, they also damage the skin, fat and other healthy tissues in the leg. When these enzymes leak out and open their cellular membranes, they release a toxic substance that bathes the fat cells and skin cells, leading to the scarred skin and fat seen with stasis dermatitis.

“This causes the skin to go from soft and pliable to thick and angry and inflamed, to red and hard and alligator-like,” describes Dr. Magnant. “It creates the skin conditions in which a minor trauma will result in an ulcer, so if you get a bump or a cut, the cut becomes a venous ulcer. But it’s the unhealthy skin that predisposes the patient to the ulceration. It’s a continuum of disease, and the disease is venous insufficiency.”

With these conditions, wound healing also becomes difficult. If the skin is unhealthy and thickened and there’s added venous pressure and liquid leaking out of the veins, the wound is going to remain open. Oxygen cannot diffuse as well through fluid as it can through healthy tissue, so when there’s extra fluid on the leg, oxygen diffusion is impaired. This distribution of oxygen across the wound is needed for healing.

“What also happens is that wounds can’t contract,” informs Dr. Magnant. “They can’t close in because there’s outward pressure from the extra fluid that’s accumulating inside. Also, due to the venous insufficiency and the high venous pressure, there is the impaired oxygen diffusion.

“Those are the three reasons wound healing is affected: impaired oxygen diffusion because of extra water, the high venous pressure of the unhealthy skin related to the substances leaking out, and the extra fluid in the leg preventing or impairing the wound contraction capability. It can’t close up.”

Dr. Magnant points out that venous insufficiency is often not considered when patients see their providers about leg ulcers that won’t heal. He adds that the medical community often ignores venous insufficiency until complications, including non-healing leg ulcers, arise.

“Oftentimes, patients are told, ‘That’s your diabetes,’” notes Dr. Magnant. “That doesn’t sound right and it’s not right. Diabetes doesn’t cause that. People with diabetes have venous insufficiency, though. Probably one out of three people with diabetes has venous insufficiency.

“We need to start considering venous disease as the medical disease that it is rather than something that should be managed expectantly until complications occur and then react to them. We need to be proactive and investigate at least to see if there’s something that is severe enough to treat and is fixable.”

If you have any of the signs or symptoms mentioned above, you may have treatable venous insufficiency and should have a thorough venous insufficiency evaluation.

Joseph G. Magnant, MD, FACS, RPVI is with Vein Specialists. Locations are 1510 Royal Palm Square Blvd., Suite 101, Fort Myers; 3359 Woods Edge Circle., Suite 102, Bonita Springs. Both offices can be reached at (239) 694-8346. Visit the practice’s websites, www.weknowveins.com and www.eveinscreening.com for more information.