Treatment of venous ulcers

Venous ulcers represent a common and debilitating condition. Many are associated with pure superficial venous incompetence and varicose veins1, but a large number, varying from 49%2 to 87%3, are due to either deep venous obstruction or deep venous valvular incompetence2. In the assessment of any apparent venous ulcer, it is most important that the state of the arterial circulation should be investigated with Doppler ultrasound and, if necessary, angiography if a diminished ankle systolic blood pressure is found3. The possibility of squamous neoplastic change in a venous ulcer must also be borne in mind (Marjolin’s ulcer), and a biopsy of the ulcer rim should be taken if there is any evidence to suggest that it might be neoplastic. A squamous carcinoma developing in an ulcer usually causes piling up and prominence of an otherwise shelving rim and multiple biopsies of the suspicious areas make the diagnosis, although the disorganized epithelium at the healing edge of an ulcer can confuse the histologist in making a categorical diagnosis of squamous carcinoma and the biopsy must, therefore, be generous. If evidence of squamous carcinoma is found, the prognosis is poor and treatment must involve wide radical excision of the ulcer and a search for associated metastatic nodes in the groin. If present, these should be treated by formal block dissection. Involvement of bone is not uncommon, in which case the only definitive treatment is amputation.