Has been bad thighs for days

Chronic venous insufficiency and an open leg

Chronic venous insufficiency (CVI, chronic venous congestion syndrome): Changes in the skin and connective tissue on the legs, especially the lower legs, as a result of persistent blood congestion when the venous return flow is disturbed. The main cause is the loss of function of venous valves in the deep venous system.

The chronic venous insufficiency is either a long-term consequence of a deep vein thrombosis and then also becomes post-thrombotic syndrome (PTS), or it is based on a congenital varicose vein formation, a primary varicose vein. In rare cases, short-circuit connections between veins and arteries (AV fistulas) are the starting point for chronic venous insufficiency.

Elderly people are particularly affected. Chronic venous insufficiency rarely leads to acute complications, but often requires long and laborious care of the affected leg, including surgical treatment of ulcers that heal poorly. The underlying blood congestion is mainly treated with compression stockings, sometimes also surgically, e.g. B. by the obliteration of varicose veins.

Leading complaints

  • Spider veins on the edges of the feet and above the ankles in connection with evening ankle edema
  • Dull pain and unbearable feeling of tension in the leg, especially after standing for a long time
  • Red-brown spots and whitish skin discoloration on the lower lower leg
  • Often reddened, oozing and flaky skin on the congested lower leg, combined with burning itching
  • Extreme susceptibility to injury: Even the smallest wounds do not heal for many days or develop into a chronic ulcer
  • In advanced stages: skin can no longer be lifted in folds, often encompasses the entire lower third of the lower leg like a gaiter and becomes coarse, hard and firm.

Pronounced chronic venous insufficiency grade II: on the left, the foot of a 70-year-old woman, which is swollen, shows bluish and white discolored areas and a spider vein-like ring of tiny veins around the ankle region. The skin is very sensitive, breaks open easily when subjected to mechanical stress (abrasions or scratches) and heals very poorly. The middle picture shows the previously open leg of a 62-year-old woman that was healed with bandages and compression. The picture on the right shows the previously open leg of a 79-year-old man, which was surgically treated: For this purpose, a superficial flap of skin was removed from the thigh, split, expanded in a mesh-like manner and the open area was thus closed.
GTVR

When to the doctor

In the next few days if

  • the symptoms mentioned worsen or appear again.

The next day if

  • An open area of ​​skin forms on the lower leg.

The illness

Disease emergence

A persistent, inadequate venous outflow disorder of the legs (the doctor also calls this inadequate decongestion) leads to increased pressure in the veins and thus to the escape of fluid and blood components into the connective tissue (edema). The cause of such drainage disorders are

Risk factors for chronic venous insufficiency are the same as for varicose veins, i.e. long standing, lack of exercise, congenital weakness of the connective tissue and pregnancy.

The permanent congestion in the leg veins leads to chronic inflammation over months and years, causing the skin and subcutaneous tissue to thicken and harden. Finally, these processes also affect the connective tissue muscle covering (muscle bandage or Fascia) above. All these hardening and thickening of the tissue impede the metabolism between the skin and the arterial blood supply.

course

Due to the inflammatory processes in the muscle fascia, the muscles enclosed in it are constricted by connective tissue and the arteries are squeezed off, which leads to a further decrease in the arterial blood supply. The poorer supply of oxygen and nutrients to the skin and the reduced removal of metabolic products lead to a considerable impairment of the natural regeneration and repair processes. In addition, the skin becomes more sensitive, more permeable to harmful substances and more susceptible to the development of allergic and infectious reactions. In addition, it becomes coarse and sensitive to injury, eczema and ultimately open spots occur, which the medical practitioner will find Leg Ulcer or venous ulcer(open leg) is called. These vacancies will not heal without expert and patient care lasting for weeks.

An open leg develops preferentially through perforating veins with leaky venous valves and through varicose veins in the lower third of the lower leg (usually on the inner ankle). The wound pain in this region is exacerbated by the foot movements. This means that those affected protect the upper ankle and it stiffens over time. The restriction of movement in the upper ankle joint reduces the effectiveness of the muscle vein pump and in turn increases the chronic venous insufficiency.

Degrees of severity

The doctor differentiates between three degrees of severity of CVI:

  • CVI grade I: Small dilated veins on the edges of the foot, associated with evening ankle edema
  • CVI grade II: Increasing edematous lower leg swelling with progressive skin damage and increased itching
  • CVI grade III: training of an open leg.

Diagnostic assurance

The doctor usually recognizes chronic venous insufficiency by visual diagnosis - especially if there are also varicose veins or the patient has already had a deep vein thrombosis. The function of the venous valves and the patency of the deep leg veins can be checked with various function tests during the physical examination (Trendelenburg test, Perthes test) - but the gold standard today is color duplex ultrasound, with which the doctor distinguishes both the veins and the flow conditions can represent.

Color duplex sonography and Doppler examinations have also largely replaced the previously necessary venography. The venography is only used if the doctor suspects a deep vein thrombosis.

Differential diagnoses. Wound healing disorders are also typical for arterial occlusive disease (PAD, smoker's leg) and the diabetic foot. Painful skin changes on the lower legs also develop in pyoderma gangrenosum as part of chronic inflammatory diseases such as Crohn's disease or rheumatoid arthritis.

treatment

Compression, exercise and surgery address the two most important goals for improving chronic venous insufficiency. These are:

  • Improve blood flow and reduce congestion
  • Bring or prevent leg ulcers to heal.

Improve blood flow

In order to end the venous blood congestion in the leg and to improve the blood flow as much as possible, the doctor can use compression treatment and, depending on the cause, surgical procedures.

  • Varicose veins. If only bulges and non-functioning valves of the superficial venous system and the perforating veins are the cause of the disease, complete normalization of the venous blood flow to the heart is possible by consistently wearing compression stockings or by surgery on the varicose veins. For more on surgical therapy, see the article Varicose veins.
  • Post-thrombotic syndrome. If the chronic venous insufficiency is based on a post-thrombotic syndrome with destruction of the venous valves of the deep leg veins, the operation of superficial varicose veins does not contribute significantly to the decongestion of the leg. The only thing left here is lifelong compression treatment to prevent permanent skin damage.
  • AV fistulas. Short-circuit connections between arteries and veins that lead to chronic venous insufficiency or other circulatory disorders are usually switched off by the doctors surgically. More on AV fistulas and their treatment under angiodysplasias and AV fistulas.

Compression treatment

The higher tissue pressure achieved by compressing the legs promotes the absorption of the tissue fluid into the veins and compresses the enlarged deep leg veins in such a way that their venous valves partially close properly again. The effectiveness of a compression treatment is greatly enhanced when the muscle vein pump is activated. Simultaneous daily movement is therefore important, during which the maximum mobility in the ankle must be used (see below, "Your pharmacist recommends").

As an additional therapy to the compression bandage, there is the possibility of one pneumatic compression therapy (intermittent apparatus compression), in which the muscle pump of the legs is imitated by alternately inflated air chambers on the patient lying down, thus improving the venous drainage. Such mechanical compression, which can also be used several times a week as part of a dressing change, contributes to faster healing. Regular lymphatic drainage massages by physiotherapists also promote decongestion of the leg.

Treatment of leg ulcers

Pharmacotherapy. If an open leg is associated with significant pain, graduated pain therapy is important to improve quality of life. However, it should also enable movement in the affected leg, which in turn has a positive effect on healing. The doctor first prescribes an anti-inflammatory pain reliever (e.g. ibuprofen or another NSAID) and combines this with opioids and, if necessary, with antidepressants. A supplementary therapy with anticoagulant drugs and the intake of zinc sulfate for zinc deficiency and vitamin C were also considered to have beneficial effects on the wound healing process.

Moist wound dressings. For local ulcer therapy, moist wound treatment has proven itself, z. B. with hydrocolloid or polyurethane dressings. They do not have to be changed every day and considerably accelerate the wound healing process compared to a dry wound dressing. Unfortunately, it is a very expensive form of therapy, which is why some resident doctors do not perform it due to budgetary reasons.

Operative ulcer therapy. The following surgical intervention options are available for extensive leg ulcers without a recognizable tendency to heal:

  • In shave therapy, the doctor surgically removes the ulcer and then closes the wound with a skin graft from the patient's thigh.
  • In fascia surgery, the thickened parts of the muscle ligament that constrict the leg muscles and their arteries are also split or removed. This reduces the pressure on the muscle fibers and arteries and improves blood flow to the wound area. The skin graft grows better and the wound heals faster.

Even long open legs can be cured by exhausting all possibilities. Often, however, only the obliteration or the surgical removal of varicose veins or the ligation of the perforating veins to the deep venous system in the ulcer area brings the desired healing. Without the lifelong wearing of a class II compression stocking, however, the ulcer cannot break open again.

forecast

Even with consistent skin care and compression, the leg ulcer often comes back after healing: The recurrence rate is around 70%.

Your pharmacy recommends

What you can do yourself

When living with chronic venous insufficiency, patient self-observation and the willingness to consistently avoid situations that lead to swollen legs and corresponding pain help.

Compression therapy.

Even if support stockings are not good for vanity, almost all people (including men) tolerate them in winter and they should not be missing in summer, at least when standing for a long time. If you torment them on hot summer days, you can get them wet in between - that cools for hours and is in any case better than taking them off. Made-to-measure compression stockings of compression classes II and III significantly improve the drainage of the legs compared to support stockings (class I is not covered by health insurance companies), even if putting them on and taking them off is tedious. It is easier to put on if you put on the compression stocking before you get up, i.e. when the leg is even slimmer. Adjusting the stockings should also be done in the morning if possible. On the other hand, it is better to try on new shoes in the evening when your feet are a little swollen.

A compression stocking remains fully functional for 6 months if worn daily, then the effect wears off. As a rule, health insurance companies pay two pairs of compression stockings per year (with a small additional payment), and the custom-made product is free of charge. For a surcharge, the wearer can have his pair of stockings colored in the color of his choice.

Everyday life and work. On which days do the legs or the leg become particularly fat? Is it hot days? Or when the sun is shining straight on your feet? Or are there certain situations, e.g. B. when shopping?

Standing jobs such as retail sales are bad. In this case, a change of profession should be considered in good time. Use a sitting ball (e.g. Pezziball®) instead of a chair when you sit for long periods in your free time.

Sleep. Many people with chronic venous problems also have trouble sleeping. You wake up sometime during the night with hot or sore calves or feet. Here, too, cooling often brings more relief than ointments. Either just leave your legs uncovered at night or, if that's not enough, place your legs on a damp towel. Raise the foot end of your bed a little to take the strain off your legs.

Move. It is good to consciously walk for half an hour a day in comfortable footwear; this also applies to patients with bare legs. Compression therapy is carried out with compression bandages or special ulcer stocking systems, with which the increased venous pressure is removed from the ulcer. If the leg muscles are well trained with optimal mobility in the upper ankle, the muscle vein pump contributes a lot to healing. If long-lasting wound pain has already restricted mobility in the upper ankle, it is therefore important to improve optimal mobility with physiotherapeutic support.

Small skin injuries. Even with the greatest care when putting on and taking off socks and shoes and when going for a walk, the smallest scratches or skin grazes cannot be avoided. In advanced cases, even the smallest injuries require weeks of maintenance, e.g. B. with antiseptic iodine ointments. Modern hydrocolloid dressings not only make care easier, they also accelerate healing. The small additional price can be worthwhile. If in doubt, go to your family doctor and ask for advice.

Complementary medicine

Herbal medicine. A number of studies show that horse chestnut seed extract is effective for treating chronic venous insufficiency, especially when used over several months. Standardized ready-to-use preparations are available (e.g. Aescorinforte® capsules, Aescusan® film-coated tablets, Perivar® Rosskaven prolonged-release tablets). For patients who cannot tolerate horse chestnut seeds, finished medicinal products based on butcher's broom root (e.g. Phlebodril mono® capsules) may be an alternative.

Buckwheat or sweet clover herb is also said to have a therapeutic effect in chronic venous insufficiency. Because of the lower concentration of active ingredients, however, tea preparations containing these medicinal plants are less effective.

Some phytopharmaceuticals are also available for the treatment of smaller local tissue defects, e.g. B. chamomile blossom extract (e.g. Kamillosan® concentrate solution for poultices) and / or finished medicinal products made from witch hazel (e.g. Hametum® cream) or marigold blossoms (e.g. Calendumed® cream). For weeping eczema, compresses with oak bark extract (e.g. oak bark extract®) can be tried.

Homeopathy. Homeopathy recommends an individually tailored constitutional treatment to alleviate the symptoms. Homeopathic remedies related to chronic venous insufficiency are e.g. B. Carbo vegetabilis or Sulfur.

Further information

  • www.phlebology.de - website of the German Society for Phlebology e. V. (DGP, Freiburg): Guidelines for diagnosis and therapy of open leg (ulcus cruris) and varicose veins.

Authors

Dr. med. Dieter Simon in: Gesundheit heute, edited by Dr. med. Arne Schäffler. Trias, Stuttgart, 3rd edition (2014). Revision and update: Dr. med. Sonja Kempinski | last changed on at 14:52


Important note: This article has been written according to scientific standards and has been checked by medical professionals. The information communicated in this article can in no way replace professional advice in your pharmacy. The content cannot and must not be used to make independent diagnoses or to start therapy.