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Venous leg ulcers (VLUs) are often the result of chronic venous insufficiency and venous hypertension, which cause retrograde venous flow or venous obstruction and require long-term monitoring and management.^1,2 Patients with chronic venous disease often have comorbid conditions that may also contribute to VLU formation and delayed healing.² It is essential to manage comorbidities appropriately,³ because uncontrolled comorbid conditions can increase the risk of VLU development.⁴

Common VLU Comorbidities and Risk Factors

Some comorbid conditions that predispose patients to VLUs are nonmodifiable risk factors, such as a family history of chronic venous insufficiency, older age, female sex, a history of thrombosis or pulmonary embolism, multiparity, and previous hip or knee replacement.^1,4 Risk factors that may be modifiable include obesity and a sedentary lifestyle.¹ Below is a brief discussion of select key comorbidities and their potential impact on VLUs.

Diabetes and Its Comorbidities

Nerve damage related to diabetes may cause a loss of foot sensation, which can lead to unrecognized injury or infection. Wounds in patients with diabetes can heal slowly and often become chronic. Peripheral arterial disease is also common in diabetes. In cases of poorly controlled diabetes, white blood cell function impairment may increase the likelihood of infection. All these complications can potentially raise the risk of VLU formation and its possible sequelae.²

Peripheral Arterial Disease and Other Vascular Conditions

When oxygen transport to tissues is inadequate, hypoxia leads to skin breakdown and wound formation. Thus, other concomitant vascular dysfunction in the setting of venous insufficiency and/or VLU poses an even more complex clinical picture. Similarly, cardiopulmonary disease, chronic obstructive pulmonary disease, and even sleep disorders all affect blood oxygenation and, consequently, tissue integrity.²

Aging

Aging skin can become fragile, and the risk of infection can therefore increase. Older persons often have chronic diseases that have negative impacts on circulation and tissue perfusion.² Partly as a result of our growing aging population, VLUs are increasing in prevalence.⁴

Immunodeficiency

Immunodeficiencies predispose patients to infection, and they also impair wound healing.²

Dementia, Depression, and Cognitive and Behavioral Issues

These comorbidities can diminish a patient’s ability to function and/or adhere to a care plan. Patients with depression and anxiety may neglect hygiene and other self-care practices, including health care.² This can also include effective home management of edema, dressings, or other vital treatment components.

Poor Nutrition

Inadequate nutrition can contribute to delayed wound healing should a VLU occur. Wound healing requires more than the normal requirements of essential nutrients.²

VLU Prevention Strategies in Patients With Comorbidities

Clinicians may choose to utilize the following measures in the prevention (and treatment) of VLUs. However, these strategies become even more important in the context of medical comorbidities. 

Compression Therapy

Selection of the best level of compression for each patient is key, as is correct application of the compression garment. Patients may resist compression therapy because it can be uncomfortable, expensive, and difficult to use (especially in patients who are frail, have obesity, or are immobile). Clinicians should work with their patients to find acceptable solutions tailored to each situation. Compression therapy should be continued even after edema has improved.⁵ Thus, it is important to arrive upon a workable approach that the patient can maintain long-term.

Diabetes Management

Patients with diabetes should receive education on the importance of tight blood glucose control to reduce the risk of infection and complications.² They should also inspect their feet every day and alert their health care provider if they see any changes.⁵

Lifestyle Modifications

A VLU prevention plan should include the following recommendations to patients⁵:

• Elevate your legs above your heart every day.
• Keep active by walking or doing calf pumps or toe-up exercises.
• Inspect your feet and legs daily and report any changes.
• Avoid sitting or standing for extended periods of time.
• If you smoke, please try to quit.
• Maintain a healthy weight and drink plenty of water.

Patient Engagement in VLU Prevention

Patient education is a necessary component of care, because venous insufficiency is a chronic condition that requires long-term monitoring and management.¹ Accordingly, having meaningful conversations with patients about the impact of their concomitant condition(s) can help paint a clearer picture of some of the challenges they may face. Evaluating and identifying a patient’s learning style could help ensure a more successful outcome.⁴ Engaging the patient (and in some cases the patient’s family or caregiver) through education can enhance adherence to the VLU prevention plan.⁴ One review found that education produced a change in patients’ beliefs about treatment, encouraged patients to develop better habits, and helped patients reach their health goals.⁶

Developing specific patient-driven goals for managing leg edema and preventing VLUs is an effective strategy.⁷ The following are sample goals that clinicians may consider⁷:

• Edema reduction through continuous compression therapy within 2 weeks of treatment initiation
• Edema prevention through long-term use of garments once achieving reduced edema
• Edema reduction by elevating affected limb above the heart at an appropriate prescribed rate
• Calf muscle and calf-muscle pump activation using elastic bands at an appropriate prescribed rate
• Walking using heel-toe gait at an appropriate prescribed rate
• Injury risk reduction by decreasing environmental hazards within 2 days
• Skin care regimen in place within 1 day
• Activities of daily living resumed within 1 month

Conclusion

Comorbidities are common in patients with or at risk for VLUs. Although appropriate management of these comorbidities can reduce the risk of VLU formation, patient engagement is a prerequisite for the success of any VLU prevention plan.

References

1. Robles-Tenorio A, Lev-Tov H, Ocampo-Candiani J. Venous leg ulcer. [Updated 2022]. In: StatPearls. StatPearls Publishing; 2024 Accessed April 2, 2024. https://www.ncbi.nlm.nih.gov/books/NBK567802/

2. Understanding comorbidities affecting venous leg ulcers. Practice Accelerator. WoundSource.com. 2020. Accessed April 2, 2024. https://www.woundsource.com/blog/understanding-comorbidities-affecting-…

3. Garavello A, Fransvea P, Gilardi S, Fiamma P. Venous ulcers: look at the patient, not at the ulcer! Risk factors and comorbid conditions in venous ulcers of lower limbs. Minerva Cardiol Angiol. 2023;71(5):575-581.

4. Factors that delay wound healing in venous leg ulcers. Practice Accelerator. WoundSource.com. 2021. Accessed April 2, 2024. https://www.woundsource.com/blog/factors-delay-wound-healing-in-venous-…

5. Venous leg ulcers: 4 ways to help improve patient compliance and quality of life. Medline.com. 2021. Accessed April 2, 2024. https://www.medline.com/strategies/skin-health/venous-leg-ulcers-4-ways…

6. He B, Shi J, Li L, et al. Prevention strategies for the recurrence of venous leg ulcers: a scoping review. Int Wound J. 2024;21(3):e14759.

7. Evans R, Kuhnke JL, Burrows C, et al. Best practice recommendations for the prevention and management of venous leg ulcers. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada. Canadian Association of Wound Care; 2019. Accessed April 2, 2024. www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop…