Dr. Windy Cole is an Adjunct Faculty member at Kent State University College of Podiatric Medicine and board certified by the American Board of Podiatric Surgery and a Fellow of the American College of Foot and Ankle Surgeons. Her interest is in limb salvage and wound care, and she currently serves as the National Director of Clinical Safety, Quality and Education for Woundtech.
Millions of Americans are afflicted with painful, open, draining ulcers on their lower extremities. Venous leg ulcers (VLUs), cause a significant clinical and economic burden to the health care system and society.1,2 It is not uncommon for clinicians to see patients who have diabetes and also suffer from VLUs.
The Problem
VLUs form as the result of chronic venous insufficiency, which is caused by an abnormality of the veins in the legs. The lower extremity venous system is composed of both a superficial (shallow) and deep system connected by an elaborate series of perforating veins.2,3 Under normal conditions, valves within these veins direct blood from the superficial into the deep system, carrying the blood back towards the heart. Blood flow in the deep system is directly impacted by the pumping action of leg muscles during physical activity.
A host of illnesses and disease states can directly affect the venous system. Deep vein thrombosis, for example, damages the valves in the veins of the deep and superficial systems. Pregnancy increases the risk of chronic venous insufficiency and VLUs: elevated hormone levels and damage to the inferior vena cava vein caused by pressure from the growing fetus create functional and structural changes in the venous system.4 In addition, there is a hereditary predisposition toward valvular dysfunction, eventually leading to the development of VLU. Obesity and a sedentary lifestyle can also contribute to the development of venous insufficiency.
The common reason for venous insufficiency is the reversal of blood flow from the deep to the superficial venous system.2,3 This reversal leads to pooling of the blood and fluid in the legs. Patients may experience swelling or edema in the lower extremities as a first sign of disease. Over time abnormal changes appear on the layers of skin tissues. Skin darkens and can become dry, itchy and flakey. Scaring may appear around the ankle and the skin can harden. Patients also may experience the loss of their hair and thickened nails. As a result of these changes, skin can breakdown and form a wound or ulceration. VLUs typically appear near the ankle, where perforating veins connecting the superficial and deep systems are located.
Diabetes and Venous Insufficiency
Is there a link between diabetes and venous insufficiency? Well, let’s just say that relationship is “complicated.” While diabetes may not directly cause venous insufficiency, it does have an effect on the tissues of the lower extremities. When diagnosed together, these disease states can have an overwhelming negative effect.
There are many underlying health and lifestyle factors seen in patients with diabetes that can contribute to the development of venous disease. High blood glucose levels can weaken the structure of the vein walls and cause damage over time. Additionally, weight gain associated with uncontrolled diabetes can place additional strain on the venous system.
A study conducted by Mani and colleagues examined the point of prevalence of venous disease in the diabetic population.4 The investigators found a significantly higher level of venous incompetence in their study cohort than had previously been reported.4 Furthermore, they reported that the study results suggested blood flow and skin changes in diabetic patients with and without foot disease.4 Conclusions can be drawn that if the blood flow changes seen in the venous system of diabetic patients can be controlled, there is potential to decrease the number of diabetic foot ulcers that occur. Additional studies are needed to prove this hypothesis.
CVI Management
Edema causes an alteration in the interior surface of the blood vessel that begins a complex cascade of detrimental events. Neutrophils become activated and adhere to capillary walls thus creating tissue injury releasing free oxygen species.5 The resulting inflammation damages the vasculature and soft tissues.5 As hypoxia (low oxygen levels) ensues, inflammation worsens, and eventually ulcerations occur.5
Compression therapy facilitates the removal of lower extremity edema. White blood cells detach from the endothelium, the thin membrane that lines the inside of the heart and blood vessels. Inflammation lessens. As perfusion, the passage of fluid through the lymphatic system or blood vessels improves the tissue environment stabilizes and tissue fibrosis decreases. Finding a compression therapy solution that is also safe and effective in diabetic patients, including Juzo products, could have additional benefits in this at-risk patient population.
References
- Ballard JL, Bergan JJ, editors. Chronic venous insufficiency. Diagnosis and treatment. London: Springer-Verlag, 2000.
- Negus D. Leg ulcers: A practical approach to management. 2nd ed. Oxford: Butterworth Heinemann, 1995.
- Olivencia JF. Pathophysiology of venous ulcers: surgical implications, review and update. Dermatol Surg 199: 25:880-885
- Mani R, Yarde S, Edmonds M. Prevalence of deep venous incompetence and microvascular abnormalities in patients with diabetes mellitus. Int J Low Extrem Wounds. 2011 Jun;10(2):75-9.
- Martani F. (Ed.) Compression: consensus document based on scientific evidence and clinical experiences. The Compression Therapy Study Group. Task Force 2009. Farrara University, Torino Italy.
If you’re living with diabetes, check out Juzo’s POWER RX medical compression socks. Our moisture-wicking fast drying, seamless socks protect sensitive skin, helping prevent foot ulcers and irritation. And, be to follow us on Instagram, @JuzoCompression and Facebook to learn more about Juzo products and resources.