Understanding Ischemic Ulcers : Causes, Symptoms, and Treatment Options

1. Introduction

   1. What are Ischemic Ulcers?

      Ischemic ulcers are chronic wounds that occur as a result of inadequate blood flow to the tissues. They occur mostly in the areas where the blood supply is compromised due to arterial insufficiency that is usually caused by atherosclerosis or peripheral artery disease (PAD)⁽¹⁾

      Ischemic ulcers are primarily seen occurring in the lower extremities such as feet, ankles, and lower legs. This deprives the tissue of oxygen and essential nutrients, leading to tissue damage, ulceration, and impaired wound healing. These ulcers are deep, painful, and non-healing and are prone to infection and further complications if left untreated.
      

   2. Importance of Understanding Symptoms and Treatment Options

      It is important to understand the symptoms and treatment options of ischemic ulcers due to the following reasons: 

      • Enabling healthcare professionals to identify potential cases early. This helps in timely intervention.
      • The healthcare professional can implement appropriate interventions that can be helpful in alleviating symptoms and improving the overall quality of life.
      • This can be helpful in preventing the progression of ulcers and the development of severe complications.
      • Knowledge about ischemic ulcers can help in making informed decisions and taking appropriate actions to prevent and manage the ulcers effectively.
      • Understanding the symptoms can help in facilitating effective communication and collaboration among professionals, leading to comprehensive and coordinated care for the individuals.

2.  Causes of Ischemic Ulcers

   The main cause of peripheral ischemic ulcers is reduced blood flow to the tissues due to inadequate oxygen and nutrients.

   Peripheral artery disease can be the main cause of reduced blood flow. Other reasons include: 

   • Atherosclerosis: It occurs due to the fatty deposits called plaques that narrow the blood vessels. Atherosclerosis is commonly associated with smoking, high blood pressure, high cholesterol level, diabetes, and a sedentary lifestyle.
   • Peripheral Artery Disease: It refers to the narrowing or blockage of the arteries supplying blood to the extremities including legs and feet.⁽²⁾ PAD is often a result of atherosclerosis that reduces the blood flow and leads to the development of ulcers.
   • Diabetes: Those suffering from diabetes are at an increased risk of developing ulcers.⁽⁴⁾ It occurs due to the potential to the blood vessels and peripheral neuropathy. The blood flow is impaired due to these conditions making them prone to ulcers.
   • Blood Clotting Disorders: Certain medical conditions such as deep vein thrombosis can lead to the formation of blood clots within the arteries and restrict the blood flow and cause ischemia.
   • Vasculitis: Inflammation of the blood vessels affects the arteries and impedes blood flow. Conditions such as Buerger’s disease or systemic lupus erythematosus can cause vasculitis and contribute to the development of ischemic ulcers.⁽⁵⁾
   • Other Risk Factors: Additional factors that may contribute to the development of ischemic ulcers are smoking, a sedentary lifestyle, and a history of cardiovascular disease.

    Ischemic ulcers can result due to a combination of factors or even a single cause.

3. Symptoms of Ischemic Ulcers

   The symptoms of ulcers may vary in severity and location. Some of the common symptoms include:

   • Pain and discomfort are often described as aching, throbbing, or sharp. The discomfort may worsen with activity or elevation of the affected limb.
   • The skin around the ulcer may appear pale, bluish, or purple due to reduced blood flow and oxygenation. The skin may appear red or mottled.
   • Ischemic ulcers have a slow healing process as the lack of blood supply hinders the healing process.
   • The wound may be shallow or deep. They may have irregular edges and unhealthy and necrotic surrounding. The presence of necrotic tissue may indicate compromised blood flow and potential infection risk.
   • The affected area may be cold due to reduced blood flow and poor circulation.
   • There may be hair loss or thinning of hair on the affected area. There may be thickening and discoloration of nails. There may also be slowed growth of nails.

   Additionally, a person with ischemic ulcers may have intermittent claudication, which is pain and cramping in the leg that occurs during physical activity.

4. Diagnosis of Ischemic Ulcers

   The diagnosis of ischemic ulcers involves physical examination to look for the signs of ischemia, which may be a lack of pulse or a bluish or pale appearance of the skin.⁽²⁾

   Tests may be done to assess the blood flow, blockages, and tissue damage to support the doctor’s diagnosis. These tests include: 

   • Capillary refill time that involves compressing the skin and measuring how long it takes to refill with blood.
   • Buerger test is done that involves elevating the leg to see if the foot turns pale.
   • Ankle-Brachial Index is the measurement of blood pressure in the ankle and compares it to the brachial blood pressure. The difference in the pressures indicates the reduced blood flow to the lower extremities suggesting a peripheral artery disease.
   • Doppler ultrasound is ordered that uses sound waves to measure the blood flow in the affected area.
   • Transcutaneous oximetry measures the oxygen supply around the wound.
   • Angiography is another test that uses special dye and X-ray to create detailed images of the blood vessels.

   Other tests may be ordered to determine the root cause of the ulcer, if the above tests are unable to detect the underlying cause of the reduced blood flow.

5. Treatment Options for Ischemic Ulcers

   The aim of the treatment of ischemic ulcers is to improve the blood flow to the affected area to promote wound healing, prevent infection and alleviate the symptoms. The treatment options may vary depending on the severity of the ulcers and the underlying cause. 

   • Lifestyle Modification and Wound Care:
     • Stopping smoking, as it is known to reduce blood flow and impair wound healing.⁽³⁾
     • Managing underlying conditions such as hypertension and high cholesterol is essential for vascular health.
     • Regular wound cleaning is important to create an optimal environment for healing.
   • Medications: Antiplatelet medications like aspirin and clopidogrel help in reducing the risk of blood clots. Vasodilators promote blood vessel dilation and may be given to improve the blood flow to the affected area. Pain medication may also be given to alleviate the discomfort associated with ischemic ulcers.
   • Revascularization procedures:
     • Angioplasty and stenting may be done for arterial blockage. It involves inserting a balloon-tipped catheter into the narrowed artery and inflating the balloon to widen the vessel.
     • In some cases, bypass surgery may be done that involves using a graft to reroute the blood flow around the blocked artery and restore the blood supply.
   • Advanced Wound Therapies:
     • Negative pressure wound therapy is an option in which a vacuum device is applied to the wound to promote healing. It removes excess fluid, improves blood flow, and facilitates the growth of healthy tissue.
     • Hyperbaric oxygen therapy involves breathing pure oxygen in a pressurized chamber that enhances the oxygen delivery to the tissue and promotes wound healing.
     • Certain advanced wound care products such as growth factors and bioengineered skin substitutes may be used to facilitate tissue regeneration and wound closure.
   • Education and Self-care: Proper foot care including regular inspection, moisturizing, and appropriate footwear can be helpful in preventing complications and reducing the risk of recurrence of ulcers. Engaging in regular exercise improves blood circulation and promotes overall vascular health. Eating a balanced diet can help promote wound healing and support overall cardiovascular health.

    Regular follow-up visits and ongoing monitoring is essential to track progress and address any complication and adjust the treatment plan as needed.

6. Complications and Prognosis of Ischemic Ulcers

   Complications associated with ischemic ulcers include: 

   • Bacterial infection due to compromised blood flow, impaired immune response, and presence of necrotic tissue.
   • Prolonged ischemia may lead to tissue death and lead to the development of gangrene.
   • Bacterial infection of the deeper layers of the skin and underlying tissue is known as cellulitis. It can occur as a complication of ischemic ulcers.
   • The wound healing may be affected by impaired blood flow and impaired oxygenation.
   • There are high chances of recurrence of ischemic ulcers, particularly if the underlying cause is diabetes or peripheral artery disease which are not properly managed.

Ischemic ulcers occur due to reduced blood flow to the affected tissue such as the lower limbs. It can occur due to various conditions that affect circulation.

Treatment stresses addressing the underlying condition and involves wound care, medication, lifestyle changes, and procedures involved in restoring blood flow.