What is it?
A skin ulcersimply means a loss of a patch of skin. There are many causes for this. In your case, the cause comes from the veins just under the ulcer. Your veins are a little bigger than normal. These are called varicose veins because they look a bit like a wine bottle from ancient Greece (varix). A varicose vein is a superficial (close to the surface) vein lying under the skin. It has swollen because of overspill of blood from veins running deep in the muscles of the legs. This happens because certain valves that allow the blood to flow from the superficial to the deep veins of the leg and not the other way around are not working any more. The problems with your varicose veins are not their size, but the high pressure and sluggish flow of blood inside them. These cause aching, cramping, itching, staining of the skin, eczema and finally ulcers. The ulcers are often very painful. They can bleed and get infected. In the long term they can range from a minor handicap to possible serious illness. Most varicose ulcers will heal. The key to the treatment is to put continuous pressure on the underlying veins. One of the best ways of doing this is to squeeze the veins with bandaging. The latest way of bandaging is to use four different types of bandage all at the same time. This is what you may have. The pressure dressing is far more important than any ointments, powders, granules, or dressings on the skin. Sometimes the blood supply is not good to the leg. The skin is starved of blood as well as being damaged by the pressure. The doctors may need to do special tests and suggest other treatment for this.
You will not need to have any anaesthetic. The aim is to get your ulcers healed. This means you wear a bandage on your leg for as long as it takes. Most people heal up inside 16 weeks. You need to have the bandages changed each week. Your ulcers are measured to make sure they are healing up. Once the ulcers have healed, the aim is to keep them that way. This might mean injection treatment, or an operation for some people. For others, some type of support stocking may always be needed. When you see the surgeon, he will check you have straightforward varicose ulcers and nothing else. He will also look into any other surgical problems you may have.
Prior to the operation you will need a period of bed rest and elevation of the legs to reduce the swelling (oedema) of the legs. At the same time you will be given antibiotics to reduce the inflammation (cellulitis) of the skin around the ulcers.
The first step of the operation is for the ulcers to be measured. A probe test may be done to check the circulation. A specimen of the discharge is taken for the laboratory to examine for the presence of any bugs in the ulcers. This will guide the antibiotic treatment that you will need in the future. The ulcers are cleaned. A non-stick dressing is put on the ulcer. Four layers of special bandages are wrapped round your leg from the knee down to the base of your toes. The doctors arrange to see you again each week. You may need to take antibiotics when they have a report from the laboratory.
There are dozens of dressings, powders, sprays, etc. on the market, but none of them do much good. You can get the ulcer to heal by getting rid of the excess pressure in the veins simply by going to bed with your feet up. This takes about three weeks. It may be best to do this in hospital. Skin grafting on its own is not very effective.
Before the operation
All your old dressings are taken off. You are given a general check over.
After - In Hospital
There may be some discomfort. Painkillers such as paracetamol should be all you need to control the pain. If the painkillers are not strong enough, contact the dressing clinic or your own doctor.
There may be some swelling of the surrounding skin which also improves in 2 to 3 days. After 7 to 10 days, slight crusts on the wound will fall off. The cellulose varnish will peel off and can be assisted with nail varnish remover. Occasionally minor matchhead sized blebs form on the wound line. These settle down after discharging a blob of yellow fluid for a day or so. You can wash the wound area as soon as the dressing has been removed. Soap and tap water are entirely adequate. Salted water is not necessary. The nurses will talk to you about your home arrangements so that a proper time for you to leave hospital can be arranged. Some hospitals arrange a check up about one month after leaving hospital. Others leave check-ups to the General Practitioner. The nurses will advise about sick notes, certificates etc. You may need to see the Haematology specialist after your operation. This will be arranged.
After - At Home
The bandages need to stay on day and night until the ulcers have healed. That is until the skin has grown over again. Three out of four ulcers will have healed within 12 weeks or so. Most of the others will have healed within a further six weeks. It is very rare for an ulcer not to heal. Sometimes other treatment, such as a stay in hospital is needed. Do not get the bandages wet or they will become rather smelly and unpleasant. Wash the rest of yourself with ordinary water and soap. You can cover the bandages with polythene bags to keep them dry. Just eat your normal diet.
Eat less if you are overweight. Take your usual medications. If you can sleep with the foot of your bed raised 6 inches (15cm.), this will be helpful. The bandages will make ankle movements a little stiff. Check that you can use the foot pedals easily before you drive. You can restart sexual relations within a day or so, when the bandage is comfortable enough. You should be able to do a light job straight away. It is sensible so avoid a dirty or a wet occupation. Walk as much as you can. Three miles a day is an ideal distance. Do not stand without moving for more than 10 minutes at a time. It is better for you to sit down with your foot up on a stool if you are not walking.
Minor problems include:
- the bandage is too tight
- the bandage is too loose
- discharge coming through the bandage.
This can be easily solved by removing the bandage, cleaning the ulcer and putting on new bandages and applying “just the right” pressure. More severe problems include:
- severe pain
- fever (signs of infection)
If the infection is very localised, it can usually be settled by taking antibiotics for a couple of weeks. Spreading of the infection into the tissues lying deep under the ulcer or into your bloodstream is a serious condition. It will require you to stay in the hospital and take antibiotics given into one of your veins and possibly an operation to clean the infected tissues.
Bleeding is very rarely a serious problem. Most of the time it consists of some oozing under the bandages and can usually stopped by applying some extra pressure. Very rarely it will require another operation to stop it.
In order to prevent the recurrence of a healed ulcer you will need to wear supportive stockings in the long run. If you are compliant with this treatment the chance of the ulcer coming back is about 16%. If you are not, it can be much higher.
You will need to be patient, but the ulcers will nearly always heal in time. These notes will help you through your procedure. They are a general guide. They do not cover everything. Also, all hospitals and surgeons vary a little. If you have any queries or problems, please ask the doctors or nurses.