752

INVITED COMMENT

Chronic leg ulceration of various causes has beena health care problem throughout history. The prob-lematic consequences of the disease and the difficul-ties in the promotion of healing conditions once cre-ated the need for a special saint for chronic leg ulcers,St Peregrinus. At one of the oldest hospitals inSweden, patients with leg ulcers comprised a largeproportion of all in-hospital patients during the years1767 to 1771.1 Both internal (laxatives) and external(turpentine, honey) treatment options were used,and, after a couple of months, at least some of theulcers healed. Bandaging therapy was mentionedalready in the Old Testament of the Bible (Isaiah1:6). In 1916, John Homans2 classified ulcers as vari-cose and postphlebitic: the first was curable with vari-cose vein surgery, and the latter was practically notcurable with surgical methods. To correctly treatchronic leg ulcers, it is a prerequisite to have adetailed knowledge of the cause and the distributionwithin the population. The aim of this report is toreview the epidemiologic situation on the basis ofdata primarily from Sweden, with special emphasis onthe impact of venous disease. A chronic leg ulcer isdefined as any wound below the knee, the footincluded, that does not heal within a 6-week period.One important problem is the multifactorial etiologyof leg ulcers, and there are many contributing factors(eg, venous thrombosis, arteriosclerosis, diabetes,tumors, arthrosis, collagenosis, varicose veins).Another problem is that approximately 30% to 40%of ulcers may have more than one cause, which willinfluence how to treat the patient and the ulcer.3-5

PREVALENCE OF LEG ULCERS

Differences in leg ulcer prevalence between vari-ous studies may have several causes, such as the useof overall or point prevalence, the inclusion or exclu-sion of foot ulcers, the age and sex distribution inthe patient series, and the methodology of identify-ing patients. With a combination of questionnairesto the health care system (eg, wards, outpatient clin-ics, nurses) and questionnaires to randomly selectedindividuals within the population and a thoroughinvestigation of the random samples of responders, itwould seem as if an optimal estimate is obtained. Wehave been especially interested in an investigation ofthe ulcer situation in three Swedish regions—the cityof Malmö (urban population), the county ofSkaraborg (rural population), and the county ofUppsala (mixed population). The populations in thethree regions are fairly similar (250,000 to 300,000inhabitants).

One obvious problem is the large number ofpatients, especially younger male patients, who arenot known to the health care system.6,7 Thesepatients take care of the ulcers themselves, andamong them, there are, without doubt, patients withcurable diseases, such as superficial venous insuffi-ciency. The overall or lifetime prevalence is roughlythree times higher than the point prevalence, andthere is a clear increase with age (Table I). The lifetime prevalence includes all the people who haveever had a leg ulcer, whereas the point prevalencemeasures the people with open ulcers during a lim-ited period of time. The point prevalence gives theactual size of the problem and thereby an estimate ofthe workload of the health care professionals at anypoint of time. With a combination of the resultsfrom three comparable studies in Skaraborg countyand the city of Malmö, 2.4% of the adult populationolder than 15 years had ever had leg ulcers and 5.6%of people 65 years or older had open or healed lowerlimb ulceration.6-10 The yearly incidence rate can beestimated to be between 0.03% and 0.06%.5

Chronic leg ulcers: The impact of venousdiseaseDavid Bergqvist, MD, PhD, Christina Lindholm, RN, PhD, and Olle Nelzén,MD, PhD, Uppsala, Sweden

From the Department of Surgery and Centre of Caring Sciences,Uppsala University Hospital.

Reprint requests: Dr David Bergqvist, Professor of VascularSurgery, Department of Surgery, University Hospital, S-751 85Uppsala, Sweden.

J Vasc Surg 1999;29:752-5.Copyright © 1999 by the Society for Vascular Surgery and

International Society for Cardiovascular Surgery, NorthAmerican Chapter.

0741-5214/99/$8.00 + 0 24/9/96438

CAUSES AND CHARACTERISTICS OF LEGULCERS

There are many causes of leg ulcers. The prob-lem is even greater in that one patient may have sev-eral causes and that this may vary with time. So, apatient with a long-standing, pure venous ulcer mayhave arterial insufficiency develop with increasingage, which adds to the problem and makes treat-ment more difficult. One etiological classification isexemplified in Table II, where there is a combina-tion of clinical and physiologic findings and the clin-ician decides on the most probable cause. A randomsample of the patients in the Skaraborg prevalencestudy was investigated by a clinician. In Table III,the main causes of chronic leg ulcers in the threeSwedish regions previously mentioned are summa-rized. One important methodologic differenceshould, however, be noticed. In the Skaraborg study,the diagnosis was established on the basis of onephysician’s combined clinical and physiologic inves-tigation. In the two other counties, the diagnosiswas made on the basis of a questionnaire, mostly theclinical investigation by a large number of nurses.Venous and nonvenous ulcers have a difference indistribution, with nonvenous being more peripheral-ly located. So, only 9% of the foot ulcers are venousand 55% are nonvenous.

The distribution of venous insufficiency in 463legs with current ulcers3 can be seen in Table IV.This classification was made with a combination ofclinical and hand-held Doppler scan examinations(before the era of duplex scanning). Of those caseswith venous insufficiency, 47% were purely superfi-cial and 53% were deep, in 42% with a superficialcomponent as well. This is important because ulcersthat are caused by superficial insufficiency are poten-tially curable with surgical treatment.3,11,12 Theinfluence of previous deep venous thrombosis is dif-ficult to evaluate, but the frequency is high in olderstudies without anticoagulant treatment.13-15 In arecent series with adequate treatment, the frequencyhas decreased, but between 5% and 10% of the

JOURNAL OF VASCULAR SURGERYVolume 29, Number 4 Bergqvist, Lindholm, and Nelzén 753

patients still have ulcers develop with time.16,17 Ifpatients with current ulcers are analyzed retrospec-tively, approximately 25% have a history of deep veinthrombosis.3 Of 287 patients without poplitealreflux, 29 (10%) had a history of deep vein throm-bosis; of 176 with popliteal reflux, 86 (49%) hadsuch a history; and, moreover, 65 (37%) had a his-tory of major surgery or fracture, in which we knowthat the risk of deep vein thrombosis is high. Amongpatients with venous ulcers, 37% had a history ofprevious thrombosis.11 A positive history of throm-bosis was significantly more common in patientswith deep vein insufficiency (54%) as compared withpatients with ulcers from isolated superficial veininsufficiency (14%).

There are several important differences betweenvenous and nonvenous ulcers, some of which areshown in Table V. Because the median age of thepatients is high, there is also a high frequency ofassociated diseases. Those patients with arterialulcers have a higher frequency of diabetes, myocar-dial infarction, and intermittent claudication than dothose patients with venous ulcers, who, on the otherhand, have more deep vein thrombosis and varicoseveins.5 The various ulcer groups do not differ insmoking habits.

SOCIOECONOMIC FACTORSTo analyze the socioeconomic factors, 78

patients with leg ulcers were compared with 271control patients without ulcers, all of whom wereidentified in a population survey in Malmö and

Table II. Etiologic classification of chronic legulcers with examples from the Skaraborg study3 (%)

No. of ulcers No. of isolatedabove the foot foot ulcers

Etiologic classification (n = 353) (n = 110)

Venous 52 2Mixed venous/arterial* 18 1Mixed arterial/venous† 4 5Arterial 4 19Arterial and diabetes 2 34Diabetes 1 14Traumatic 2 1Pressure <1 13Multifactorial (arterial, venous, 3 3

diabetes)Multifactorial (others) 8 4Other single causes 6 4

The classification was made by one surgeon who combined clini-cal and physiologic findings.*Venous cause dominating.†Arterial cause dominating.

Table I. Overall prevalence of leg ulcer inSkaraborg county (%)

Known to health care system Self care included

All causes Venous All causes Venous

Total population 0.90 0.49 1.90 1.03>15 years old 1.20 0.65 2.40 1.30>64 years old 4.20 2.27 5.60 3.02

Skaraborg.5 Except for a significantly lower incomein the ulcer group, there was a surprising lack of dif-ferences in socioeconomic factors. So, 74% of thepatients with ulcers earned less than $12,500 peryear as compared with 50% of the patients withoutulcers. One important factor is the high frequency ofimmobile patients with leg ulcers. In the Skaraborgstudy, only 40% walked without some sort of sup-port and 18% used a wheelchair regularly.

PRESENT TREATMENTLeg ulcer treatment by tradition has been con-

sidered of secondary interest by most health careworkers. This is reflected in the large number of var-ious local treatments found in a recent survey inUppsala county in which 113 types of local woundtreatments were identified. Dressing changes weremade by district nurses in 52% of the cases, by otherhealth care workers in 40%, by relatives in 2%, and bythe patients themselves in 6%. In 6% of the patientswith venous ulcers, the dressings were changed 2 to3 times daily; in 36%, once daily; in 37%, 2 to 3times a week; and in 21%, once a week.11 In theSkaraborg study, 74% of the patients with venousulcers used daily compression as compared with 22%of the patients with nonvenous ulcers.11 Pain is amajor problem in both venous and nonvenous legulcerations.18,19 In an interview study in theUppsala county, 89% of all the patients with legulcers reported pain. The annual cost of venous leg

ulcer treatment in Sweden has been calculated to250 Swedish Kroner per day, which would be a year-ly cost in Sweden of 2 billion SEK.5 This figureexcludes the people in selfcare, who induce a sub-stantial indirect cost for the society. Another way toexpress the cost is that, in a county of Uppsala’s size(290,000 inhabitants), 57 nurses were occupied fulltime with leg dressing changes, which means a costfor salary of approximately 15 million SEK per year.

PROGNOSISIn the Skaraborg study, at a mean follow-up peri-

od of 54 months, 54% of the venous ulcers werehealed, 43% were open, and 3% of the legs wereamputated.20 In Uppsala, 40% of the leg ulcers werehealed within 3 months. The recurrence of healedvenous ulcers is common. In patients with currentvenous ulcers, as many as 33% have their fourthepisode of ulceration and 60% to 70% are alreadyrecurrent.11,21 The long-term outcome for patientswith ulcers caused by deep venous insufficiencyappears to be worse than for patients with ulcerscaused by superficial venous insufficiency or perfo-rating vein incompetence alone.11,20 To preventrecurrence, adequate compression is extremelyimportant.19,22,23 Leg ulcer clinics with dedicatedhealth care personnel, a multidisciplinary approach,and systematic care programs can at least improvethe short-term healing of ulcers in the communi-ty.24,25 Treatment in leg ulcer clinics also seems to

JOURNAL OF VASCULAR SURGERY754 Bergqvist, Lindholm, and Nelzén April 1999

Table IV. Distribution of venous insufficiency in463 legs with current ulcers (%)

Ulcer above the foot Foot ulcer

Femoral vein 27 4Popliteal vein 45 15Long saphenous vein 31 9Short saphenous vein 44 16Calf perforators 56 13

As understood from summarizing the columns, there are varioustypes of combinations.

Table III. Causes of chronic leg ulcers (%)

Skaraborg county Uppsala county Malmö city(n = 463) (n = 406) (n = 257)

Venous 40 29 34Mixed 18 14 11Arterial/diabetes 21 8 21Traumatic 2 18 2Others 19 31 32

All ulcers, including foot ulcers, are included.

Table V. Comparison between venous and nonvenous chronic leg ulcers

Venous Nonvenous P value

Median patient age (years; range) 77 (39 to 97) 77 (13 to 91)Diabetes (%) 8 47 <.001History of thrombosis (%) 37 11 <.0001Median age at first ulcer (years; range) 59 (14 to 92) 73 (12 to 94) <.001Median duration of ulcer history (years) 13.4 2.5 <.001Recurrent ulcer (%) 72 45 <.001

JOURNAL OF VASCULAR SURGERYVolume 29, Number 4 Bergqvist, Lindholm, and Nelzén 755

give a better quality of life.26 Patients with leg ulcers,as a group, have a significantly decreased 5-year sur-vival rate as compared with a matched control pop-ulation (67%).20 However, with the analysis ofpatients with ulcers on the basis of cause, patientswith venous ulcer have a normal expected survivalrate, whereas those with arterial ulcers and ulcers ofother causes have a significantly decreased survivalrate. Thus, patients with venous leg ulcers are likelyto live with their ulcers for a long period of their lifeunless a curative treatment is offered.

CONCLUDING REMARKSThe problem of leg ulcers seems to remain. The

enormous costs to the society of leg ulcers have beenrealized. An often complex etiology makes diagnosisand proper classification of ulcers essential to pro-vide optimal treatment. There is enough basic infor-mation to organize effective treatment pathways. Amultidisciplinary approach seems to be a prerequi-site for improvements in leg ulcer care. A substantialproportion of so-called “chronic” leg ulcers are notchronic provided that adequate treatment is given.Today there should be knowledge enough to sub-stantially decrease the size of the leg ulcer problem.

We thank the Swedish Medical Research Council00759.

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Submitted Oct 2, 1998; accepted Dec 2, 1998.