Introduction
Venous leg ulcers (VLUs) represent a serious clinical challenge and are a result of chronic venous insufficiency (CVI) and venous hypertension [1]. They constitute 60 to 80% of all difficult-to-heal wounds located in the lower limbs [2, 3]. The prevalence of VLUs is reported around 1.08% [4] and the incidence is up to 1.33% [5]. A multicentre epidemiological study conducted in Poland showed that active ulceration occurs in 1.26% of adult Poles, and in over 2% of patients the condition persists after healing [6]. Prevalence is higher in people between 50 and 80 years of age [7], and in people over 65 years of age, it increases to 5% [8]. The first ulceration most often appears between 40 and 50 years of age, slightly earlier in women [6]. The 3-month ulcer healing rate is estimated at 30–40% [9, 10], and in one study, even 60% [7]. The median duration of ulceration ranges from 6 to 8 months [11], although cases can last for years or even decades [12]. The recurrence rate is high – in some countries, it is as high as 70% [13]. In approximately 80% of patients, ulceration recurs within 3 months of healing [14], and approximately 26% of cases recur within the first year after treatment [15]. As many as 33% of patients experience four or more recurrence episodes [13], and in 21% of patients, ulceration recurs more than six times during the course of the disease [9, 16–18]. According to some estimates, approximately 28% of patients may experience as many as 10 recurrences during their lifetime [19]. Although the literature contains numerous studies on treatment methods and their impact on the healing process of venous ulcers, relatively few studies have focused on their clinical history.
Material and methods
Patients
This retrospective analysis focused on the medical records of patients with venous ulcers treated at the Chronic Wound Treatment Clinic/Outpatient Clinic for Chronic Wound Management at University Hospital No. 1 in Bydgoszcz between 2020 and 2023. Based on the International Classification of Diseases (ICD-10), 672 patients with diagnoses of I83.0 (Varicose veins of lower extremities with ulcer) and I83.2 (Varicose veins of lower extremities with both ulcer and inflammation) were identified in the clinic’s registry database. Observations meeting the following criteria were included in the analysis: a description of complete medical records collected during the initial visit and a normal ankle branchial index (ABI) value (0.9–1.3) [20]. Patients with incomplete medical records and an ankle-brachial index result above or below the reference values were excluded from the study.
Results
From a total database of 672 patients, 352 met the criteria. 317 patients were excluded from the study, including 188 with an ABI > 1.3 or < 0.9, and 132 with incomplete documentation. Table 1 shows the characteristics of the study group.
Table 1
Comparison of demographic and clinical characteristics of patients with venous ulcers
Age and gender
The study group included 214 (60.8%) women and 138 (39.2%) men. The largest group (70.5%) consisted of patients aged 60 and over. In this age group, the proportion of women and men was similar: women – 45.4%, men – 41.1%. We observed that the number of patient admissions increased with age up to 79 years for both women and men, while for women, this trend continued until the age of 89. At the time of presentation, 104 patients (29.5%) were under 60 years of age. This group included 8 men under 40 years of age and 18 women, the youngest of whom were at least 40 years old. Detailed data regarding age and gender are presented in Table 2.
Table 2
Age and gender of patients with ulcers
Duration of first ulcer in life
Duration of the ulcer diathesis is defined as the period of time from the onset of the first ulcer to the time of the survey and is an index of the chronicity of the condition [21]. Table 3 presents the duration of the first ulcer in a patient’s life (so-called first ulcer in life), divided into those who later developed a recurrence of the ulcer (YES) and those whose ulcer was the first and is still unhealed (NO). In 130 individuals (36.9%), the first ulcer was still active at the time of presentation to the clinic. The longest duration of a single, persistent ulcer was 54 years and occurred in a 78-year-old woman after an episode of deep vein thrombosis after childbirth. Among men, the longest such case was 37 years. In 35 (26.9%) patients – including 17 women and 18 men – the current ulcer had lasted between 10 and 60 years. In only 47 (13.3%) patients, the first ulcer had developed within the last year, while in 93 (26%) patients its duration was between 1 and 5 years.
Duration of current ulcer
Table 4 presents the duration of the current ulcer, distinguishing between those in whom it was a subsequent episode (YES) and those in whom it was still their first ulcer (NO). Of the 352 patients, 222 had a current ulcer, not their first. In most of them (n = 134; 60.4%), the current wound had recurred within the last 12 months. This was primarily the case for women (n = 92; 41.4%), but also for 42 (18.9%) men. In 72 patients, the ulcer had been present for 1 to 5 years, and in some cases, even longer than 10 years. The longest recurrent ulcer lasted 20 years (in a 74-year-old woman), while in men, the maximum duration of the current ulcer was 12 years.
Previous history of venous thrombosis
In the analysed group, 93 (26.4%) patients had a history of deep vein thrombosis, and 51 (14.5%) patients had a history of superficial vein thrombosis. Both superficial vein thrombosis (16.4% vs. 11.6%) and deep vein thrombosis (16.4% vs. 11.6%) were more common in women than in men (28.5% vs. 23.2%).
Affected leg
In the study group, the majority of ulcers (185, 52.6%) were located on the left lower limb. By gender, this affected 110 women (51.4%) and 75 men (54.3%). In 11 patients (3.1%), including 7 women and 4 men, ulcers occurred on both lower limbs.
Recurrences
At the time of admission, 63.1% of patients had already had a recurrence of a wound; 141 (65.9%) of these were women and 81 (58.7%) men. The largest group, 205 patients (58.2%), were between 60 and 80 years of age. These patients had their first (61, 17.3%), second (79, 22.4%), third (47, 13.3%), and more than three (35, 9.9%) ulcerations. Women experienced a higher number of recurrences; 4 patients had five recurrences, the same number of women had six recurrences, and 2 women had eight and nine recurrences. In the male group, 10 patients had four recurrences, and 3 patients had five ulcerations. The largest group consisted of patients who experienced a second ulcer recurrence – 79 (22.4%). These patients ranged in age from 39 to 87. The youngest man with a first recurrence was 31 years old, while the oldest – 92 years old – reported at least a third recurrence. Women aged 40–45 often experienced one to three ulcer recurrences. Table 5 presents descriptive statistics for age, gender, and number of recurrences.
Table 5
Descriptive statistics for age by gender and number of recurrences
BMI
At the time of admission, 280 (79.5%) patients were overweight or obese, with a body mass index (BMI) ≥ 25. 128 (36.4%) had a BMI of 25–29.99, including 67 (31.3%) women and 61 (44.2%) men. Ninety-three (43.5%) women and 59 (42.8%) men had a BMI above 30.
Location
In most patients (63%), wounds were located in the medial malleolus region, 23.9% were located on the lateral aspect of the ankle, 9.1% on the anterior aspect of the shin, and 2.5% on the posterior aspect. Ulcers were more frequently located in the medial malleolus region in women than in men (65.9% vs. 58.7%). In men, wounds were more common on the lateral aspect (26% vs. 22.4%) and anterior aspect of the shin (11.5% vs. 7.4%) than in women. The incidence of ulceration on the posterior aspect of the shin was comparable in men and women.
Discussion
Despite advances in medicine, venous leg ulcers remain a clinical problem and a topic of concern both locally and internationally [22]. According to O’Meara et al. [23], 1% of the Western population will experience VLU at some point in their life. The clinical history of a wound often reflects a complex interaction between the chronic nature of the disease and periodic medical interventions. According to Callam et al., without specialized care, the number of patients with wounds and the percentage of permanently unhealed ulcers would be higher [21].
Venous leg ulcers are often considered a disease of the elderly. Because it is a chronic disease, the age distribution is strongly skewed toward older adults, and as the population ages, this trend is likely to continue [21]. It is worth noting that in 42 (11.9%) of our patients, ulcers developed before the age of 50, and of these, 22 had already experienced ulcer recurrence. As expected, the number of patients with ulcers increased with age. This increase was proportional in both genders until the age of 69. However, in the group of patients with an average age of 70–79, ulcers were significantly more common in women (33.1% vs. 23.1%).
The assessment of ulcer chronicity requires consideration of the patient’s age at the time of the first episode, as it may correlate with important clinical and prognostic factors. In our study group, men developed their first ulcer earlier. In eight of them, the wound occurred between the ages of 20 and 39. We suspect that the development of ulcers in relatively young men may have been related to obesity – in 5 patients, the BMI was above 35, and in one, above 46. Similar observations were made by Musil et al. [24], who assessed the severity of cardiovascular disease (CVD) in a group of 213 patients. The authors showed that the study group included 65 men (30.5%, mean age: 45.1 ±13.9 years) and 148 women (69.5%, mean age: 47.5 ±13.5 years). Patients were divided into three age categories: 18–40 years (40.8%), 41–74 years (56.3%), and ≥ 75 years (2.8%). BMI was classified as normal weight (18.5–< 25 kg/m2), overweight (25–< 30 kg/m2), and obese (≥ 30 kg/m2). It was shown that men were younger than women (mean age 45.1 ±13.9 years vs. 47.5 ±13.5 years) and had significantly higher BMI (men: mean BMI 26.9 ±3.3 kg/m2, women: mean BMI 25.1 ±4.1 kg/m2), which influenced the clinical severity of CVD. It can be assumed that lifestyle changes contribute to reducing the differences in the impact of environmental factors on women and men [25]. In our material, however, in the other 2 young men, the ulceration was caused by trauma. Trauma is known to be a factor that can influence the development of both the first and subsequent ulceration. This is confirmed by both long-term [26, 27] and current reports [20, 28, 29].
Another indicator of wound chronicity is the duration of the ulcer diathesis, which is the time from the first ulcer to the time of examination [21]. In our analysis, as many as 130 patients presented with their first ulcer, which had not healed by the time of examination at our clinic. The average duration of ulcers was over 11 years, in women almost 12 years, indicating an exceptionally long course. In approximately one-third of patients, the wound developed within the last year, while in the remaining patients it persisted for 2 to even 60 years. Venous ulcer is most often defined as a wound that did not heal within 4 to 6 weeks [29, 30]. However, Briggs and Closs [31] noted that the threshold for chronicity varied across countries – from 4 weeks to even 3 months, which significantly influenced the estimate of ulcer prevalence. The long duration of wounds observed in our group of patients is consistent with the results reported by other authors. In a retrospective analysis by Formentini Scotton and Fernandes Abbade [32], a significant degree of ulcer chronicity was also noted. Briggs and Closs [31] reported that the average duration of ulceration in the studies they analysed ranged from 6 to 9 months, with wounds persisting for up to 72 years in extreme cases. Perhaps this is why Briggs and Closs describe lower limb ulcers as a devastating, chronic disease and emphasize that patient care should focus not only on the wound healing process but also on alleviating the symptoms accompanying their “limb ulcer journey” [31]. It is worth emphasizing that in Poland, the number of specialized wound care centres – both in the public and private sectors – has increased significantly only in the last 15 years. Our facility, established in 2000, was one of the first to provide comprehensive, interdisciplinary care for patients with venous ulcers. Unfortunately, it still happens that people with chronic wounds are treated incidentally by different specialists, and the therapeutic process is rarely preceded by a full diagnosis [33].
It has been repeatedly demonstrated [9, 34, 35] that a previous history of ulcers and a disease duration of ≥ 2 years from the first episode are significant risk factors for recurrence, and this pattern persists for decades. The literature [20, 36] cites cases of patients with repeatedly recurrent ulcers who are unable to recall how many times the ulcer recurred. In our study group, on average, every second person experienced a recurrence. A total of 522 recurrences were recorded among the 352 patients, with the number ranging from 1 to 9 during their lifetime. In the study group, women experienced venous ulcer recurrences more frequently than men – recurrence occurred in 65.9% of women and 58.7% of men. In the group of 214 women, 141 (65.9%) experienced ulcer recurrence, of whom 139 had more than two episodes. In our group, 11 patients – 7 women and 4 men – had ulcers on both lower limbs. Overall, wounds were more frequently located on the left lower limb (52.6%), with no significant differences between women (51.4%) and men (54.3%). Although epidemiological and clinical reviews do not demonstrate a clear predominance of ulcers on the left limb in either gender [26, 37, 38], most reports [24, 39] indicate that ulcers occur more frequently on the left side in women. In women, the key pathophysiological factors implicated in the aetiology of ulcers are increased venous pressure and a predisposition to deep vein thrombosis. Thakur et al. [40], similarly to our analysis, did not find a predominance of ulcers on the left lower limb in women. The authors analysed a group of 108 patients and noted that in 43.5% of patients, ulcers were located on the left and 56.5% on the right lower limb, again without a marked gender predominance. Similarly, in the population-based study by Nelzen et al. [41], no significant differences in the incidence of ulcers were found between the right and left limbs. However, the authors did not separate the data by gender or the exact location. In our group, 63.1% of ulcers were located in the medial malleolus, less frequently in the lateral malleolus (23.9%) or other areas. This location is consistent with most reports [42–44], which indicate the medial malleolus as the most common site for VLUs. This is due to the highest hydrostatic pressure in the standing position and the predisposition of this area to inflammatory and trophic changes [29, 45].
The manuscript has certain limitations, primarily due to the retrospective nature of our study and the study period. An additional limitation is the lack of standardized criteria for classifying the first and subsequent recurrences of venous ulcers.
Conclusions
Analysis of the clinical histories of patients with venous leg ulcers confirmed the chronic and recurrent nature of this disease. In many patients, the first ulcer occurred at a relatively young age, and the average duration exceeded 11 years. The recurrence rate was high – 1 in 2 patients experienced more than one ulcer, and some patients even experienced it multiple times. The long-term persistence of wounds and their recurrence indicate the need for early diagnosis, long-term care, and an interdisciplinary approach to the treatment of venous leg ulcers.
