Most chronic wounds are one of three types: venous stasis ulcers, pressure ulcers, and diabetic ulcers.1 However, a fourth group of chronic wounds—arterial ulcers—is an important cause of disability and amputation.2 While fewer people are affected by arterial ulcers than the other ulcer types, those who have arterial ulcers struggle with a uniquely difficult condition.
What causes an arterial ulcer?
As the name implies, an arterial ulcer occurs when there is a lack of arterial blood flow to a region of skin. An arterial ulcer commonly is caused by peripheral artery disease (PAD), specifically atherosclerosis in small arteries in the limbs. However, any condition that impairs arterial blood flow (e.g. arterial aneurysm, popliteal entrapment syndrome, thromboangiitis obliterans, radiation arteritis, etc.) can cause an arterial ulcer.
Without adequate blood flow, the skin and underlying tissues do not receive sufficient amounts of oxygen or nutrients that the cells need to survive. As cells die, the skin and tissues break down, leading to an ulcer (depressed wound). Once an arterial ulcer forms, the lack of blood flow to the area interferes with wound healing. Thus, arterial ulcers tend to be chronic, long-lasting wounds.
Symptoms and diagnosis
According to the American College of Cardiology and the American Heart Association, as many as half of all people with peripheral artery disease have no symptoms when they are diagnosed.3 At the other end of the spectrum, 1 to 2% of patients first seek medical treatment when they are facing amputation for severe disease.3 If symptoms do occur, the most common symptoms are unusual leg pain or leg pain during walking. If not adequately treated, peripheral artery disease will lead to arterial skin ulcers.
Arterial ulcers typically occur on the toes, heels, or other places where bones come close to the surface of the skin.4 The small, round ulcers often have sharp borders, with a “punched out” appearance. Arterial ulcers tend to be deeper than other types of ulcers. Since there is a general lack of blood flow to the area, these wounds do not bleed much and there is minimal exudate. There is minimal new tissue growth or granulation tissue. Arterial ulcers are also very painful, more so than other types of chronic wounds.
People with arterial ulcers will have evidence of poor blood flow to the extremity. Patients will have delayed capillary refill in the toes. Likewise, pedal pulses are diminished or absent. In the absence of infection, the affected area will be cool to the touch (because of reduced arterial blood flow). If one lifts the supine patient’s leg greater than 30° off the bed, allowing venous blood to drain from the area, it usually causes pain. If the diagnosis of arterial ulcer is in question, patients may undergo specific testing for peripheral arterial disease including ankle-brachial index testing, Doppler ultrasound testing, and/or angiography.5
Managing an arterial ulcer
The most pressing goal of arterial ulcer treatment is to restore blood flow to the affected area. Unfortunately, restoring arterial blood flow cannot always be done quickly. The only rapidly curative treatment is angioplasty; however, relatively few people are candidates for this procedure. Treatment involves risk factor management including smoking cessation, diabetes control, blood pressure treatment, and hyperlipidemia treatment. Regular exercise can also help improve blood flow as long as the patient can tolerate the discomfort that usually occurs with exercise. Adequate pain management is critical.
Because it can take time to restore blood flow in patients with peripheral arterial disease, arterial ulcer wound management is an essential part of care. Choosing the right dressing requires understanding three critical concepts:
- Contrary to the management of other chronic wounds, arterial ulcers must be kept dry. Moist wound healing is not recommended for these types of ulcers. Excess moisture should be removed with absorbent dressings; however, the wound should be not so dry as to cause trauma to the wound bed during dressing changes.
- Special effort must be taken to avoid infection. Infection in arterial wounds can spread rapidly and lead to osteomyelitis (bone infection). Indeed, patients with arterial ulcer wound infections can deteriorate rapidly.4 Meticulous aseptic technique should be used during dressing changes. The wound itself can be treated with antiseptic solution (not normal saline or water) as long as the wound is not overly wetted. Antibiotic ointments, on the other hand, should be avoided because they can kill human cells. Cadexomer iodine gel may be used around the wound edges.
- Blood flow to the area should be encouraged, not hampered. Thus, dressings should not compress the skin or limit arterial blood flow to any degree.
Occlusive dressings are broadly recommended for arterial ulcer wound management. This is mainly because chronic wounds that are left open have the potential to become heavily colonized and infected. Bacterial proliferation is substantially lower under occlusive dressings.6 The occlusive dressing should be impermeable to debris and bacteria. It should also not compress the wound or wound bed.
The choice of medical tape in arterial wound management is surprisingly important. The tape must be able to hold firm without compressing the underlying tissue. The tape should be occlusive, for the same reasons that the dressing should be occlusive.
Hy-Tape is the ideal choice in arterial ulcer wound management
Arterial ulcers have unique wound care requirements, and Hy-Tape meets and exceeds these requirements. Hy-Tape is fully occlusive and resists soiling and bacterial penetration. The original “pink tape” exerts maximal adhesion at body temperature, and holds strong without impairing blood flow to underlying tissues. Importantly, Hy-Tape is gentle on friable, desiccated skin, which is common in arterial ulcers. Hy-Tape’s zinc oxide-based adhesive releases cleanly and with minimal skin trauma. This makes it particularly useful for wounds that require frequent dressing changes (e.g. vascular ulcers).
Hy-Tape can secure all types of dressings commonly used in arterial ulcer wound management. For complete wound care, Hy-Tape patches provide occlusive coverage over any type of dressing.
If you or someone you care for is struggling with an arterial ulcer, you may request a free sample of Hy-Tape by visiting our website or calling 1-800-248-0101.
- Mustoe T. Understanding chronic wounds: a unifying hypothesis on their pathogenesis and implications for therapy. American journal of surgery 2004;187:65s-70s.
- Zhao R, Liang H, Clarke E, Jackson C, Xue M. Inflammation in Chronic Wounds. International journal of molecular sciences 2016;17:2085.
- Rooke TW, Hirsch AT, Misra S, et al. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology 2013;61:1555-70.
- Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ (Clinical research ed) 2006;332:347-50.
- Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Journal of vascular surgery 2007;45 Suppl S:S5-67.
- Schmidt K, Debus ES, St J, Ziegler U, Thiede A. Bacterial population of chronic crural ulcers: is there a difference between the diabetic, the venous, and the arterial ulcer? VASA Zeitschrift fur Gefasskrankheiten 2000;29:62-70.