My last column, Classification of Pressure Injuries, discussed the importance of documenting the details of pressure injuries using the updated pressure injury classification system. This column discusses the updated classification system for venous ulcers, namely, the Clinical Etiology Anatomy Pathophysiology (CEAP) classification system. To understand the use of this classification, let’s briefly discuss the etiology, assessment, and management of venous ulcers.
Venous ulcers are believed to account for approximately 70% to 90% of chronic leg ulcers.1 The incidence of venous ulceration increases with age, and women are three times more likely than men to develop venous leg ulcers.2 In some studies, 50% of patients had venous ulcers that persisted for more than 9 months, and 20% had ulcers that did not heal for more than 2 years. After healing, up to one-third of treated patients experience four or more episodes of recurrence.1 The proper diagnosis and management of venous ulcers begin with a basic understanding of the venous system of the lower extremities.
The diagnosis of venous ulceration depends on a thorough history and physical examination. In obtaining the history, the clinician should focus on risk factors such as a history of deep vein thrombosis, leg trauma (crush injury, fracture, or surgery), congenital venous abnormality, limited mobility with impaired calf muscle pump (arthritis, paralysis, muscular disorders), pregnancies, congestive heart failure, family history of venous disease, obesity, and advanced age. Women are three times more likely than men to have venous ulcers.
Characteristic clinical findings are noted in the table and include the presence of varicosities, hyperpigmentation, lipodermatosclerosis, and dermatitis. The shape of the leg may also provide a clue, as the “inverted bottle shape” is a sign of lipodermatosclerosis. Venous ulcers tend to have flat wound edges, without undermining.
Although most leg ulcers are venous ulcers, the clinician should suspect other causes when the wound looks atypical (presence of necrotic tissue, exposed tendon, livedo reticularis on surrounding skin, or a deep, “punched-out” ulcer), has been present for longer than 6 months, or has not responded to good care. Do not hesitate to take a biopsy when in doubt.
Visual and palpable assessment may not be enough to determine the next steps. Objective testing may be needed to confirm the diagnosis, determine the etiology of the problem, and identify the anatomic site and severity of disease pathway (Table).
CLINICAL FINDINGS ASSOCIATED WITH VENOUS LEG ULCERS
||30%–40% occur superior to the medial malleolus (near the saphenous vein). The rest occur mainly in the lower third of the calf.
|Appearance of wound bed
||Referred to as “ruddy” or “beefy red;” granular
||Flat, irregular wound margins without undermining
||May be moderate to heavy, depending on the amount of edema
||Venous dilation, including submalleolar venous flare (typical of venous insufficiency), telangiectasias, reticular veins, varicose veins, edema (typical of more advanced venous disease), atrophie blanche, maceration, hyperpigmentation (from hemosiderin staining), and lipodermatosclerosis. Scarring from prior healed ulcers may be noted.
||Controversial. Many believe that pain is usually not present, however several studies have reported severe pain occurring in as many as 76% of patients with venous ulcers. Deep ulcers, particularly around the malleoli, or small venous ulcers surrounded by atrophie blanche are the most painful. Generally, patients report that pain occurs with leg dependence (sitting, standing) and is reduced with leg elevation.
Reprinted with permission from Hess CT. Clinical Guide to Skin and Wound Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
DIAGNOSIS AND MANAGEMENT
Performing the appropriate diagnostic tests is paramount when evaluating the patient with a suspected venous ulcer. Testing identifies patients with venous pathology who may benefit from noninvasive or invasive treatments for vein-related symptoms, thereby decreasing the incidence of recurrent ulceration. The results of the tests also provide the basis for proper interventions and patient management. When assessing the patient with venous disease, it is crucial to rule out coexisting peripheral arterial disease.
Management of vascular ulcers has improved over the past decade as clinicians have come to realize the importance of proactive measures and an interprofessional approach. In addition, treatment modalities such as growth factors and cellular- and tissue-based products can help heal difficult wounds, accelerate the wound healing process, and prevent new wound formation to a degree not previously thought possible.3 Proper tests can detect reflux and/or obstruction and localize the anatomic site and severity of disease or identify coexisting peripheral artery disease.
The American Venous Forum has developed a system for classifying venous disease using the acronym CEAP, which stands for Clinical signs, Etiology of venous disease (congenital or primarily or secondarily acquired), Anatomic distribution (superficial, perforating, and/or deep veins), and Pathologic condition (obstruction and/or reflux). It is an internationally accepted standard for describing patients with chronic venous disorders based on clinical manifestations and the underlying venous pathology. Originally developed in 1993, the CEAP classification system was revised again this year. The changes in the 2020 version include the following:
- adding corona phlebectatica as the C4c clinical subclass
- introducing the modifier “r” for recurrent varicose veins and recurrent venous ulcers
- replacing numeric descriptions of the venous segments by their common abbreviations4
The key to treatment of any chronic wound is to address the underlying problem. It is important to build your initial and follow-up assessment documentation and management workflows. Consider the following approaches upon initial assessment when caring for a patient with venous insufficiency:5
- Prepare the wound bed to convert the molecular and cellular environment of a chronic wound to that of an acute healing wound.
- Rule out arterial etiology, confirm venous etiology, and evaluate blood flow with the use of noninvasive tests.
- Apply compression when appropriate.
- Remove avascular tissue when appropriate.
- Manage infection: obtain culture and incorporate antimicrobial dressings, if required.
- Optimize nutrition: obtain a dietary consult.
- Protect the skin surrounding the ulcer.
- Control moisture with the appropriate dressing products.
- Initiate wound measurements and outcomes: measure wound healing with the use of a validated digital wound measurement and analysis tool and monitor outcomes.
- Provide patient education and continually assess patient/caregiver understanding of the treatment plan.
Although approximately 70% of venous ulcers heal within a 24-week period, 30% are unhealed after this time.6 Data suggest that a venous leg ulcer that fails to decrease in size by 30% (percentage area reduction) of its initial size over the first 4 weeks of treatment has a 68% probability of failing to heal within 24 weeks.7 Using the successive 4-week benchmark,5 providers should consider the following approaches:
- Reevaluate patient status with a complete patient history, physical examination, and plan of care; review initial approaches.
- Monitor healing and outcomes; continue to use a validated digital wound measurement and analysis tool and monitor outcomes.
- Sponsor granulation; consider alternative technologies for wound management.
- Introduce growth factors and/or cellular- and tissue-based products.
- Revisit diagnosis; rule out differential diagnosis of lower extremity ulcers.
- Provide patient education and reinforce adherence to the treatment plan.
The use of proper workflows coupled with noninvasive vascular testing facilitates identification of the anatomic and pathologic aspects of this system. Use of the updated CEAP classification system provides a reliable and reproducible classification of the many manifestations of chronic venous disease.
1. Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen 2009;17(6):763–71.
2. Hellström A, Nilsson C, Nilsson A, Fagerström C. Leg ulcers in older people: a national study addressing variation in diagnosis, pain and sleep disturbance. BMC Geriatr 2016;16:25.
3. Agency for Healthcare Research and Quality. Skin substitutes for treating chronic wounds. January 2019. www.ahrq.gov/sites/default/files/wysiwyg/research/findings/ta/drafts-for-review/skin-substitutes_draft.pdf
. Last accessed September 22, 2020.
4. Lurie F, Passman M, Meisner M, et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg 2020;8(3):342–52.
5. Hess CT. Clinical Guide to Skin and Wound Care. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013.
6. Parker CN, Finlayson KJ, Edwards HE. Predicting the likelihood of delayed venous leg ulcer healing and recurrence: development and reliability testing of risk assessment tools. Wound Manage Prev 2017;63(10):16–33.
7. Kantor J, Margolis DJ. A multicentre study of percentage change in venous leg ulcer area as a prognostic index of healing at 24 weeks. Br J Dermatol 2000;142(5):960–4.