A leg ulcer is defined as tissue impairment that results in the formation of open sores or wounds associated with skin breakdown. Venous ulcers are frequently identified on the legs because of venous blood pressure, insufficiency, or trauma. The most widespread types of leg ulcers are arterial and venous.

Somatic ulcers, or arterial leg ulcers, are ulcers generated by poor blood circulation in the limbs' arteries caused by ailments such as atherosclerosis or PAD. While VUs are usually painless and located in the calf region, ALUs are very painful and occur in the lower leg or feet.

The details of the development, signs, and symptoms of arterial leg ulcers require careful understanding for effective differential diagnosis and management. For people affected by this disease, it is now possible to diagnose it in its early stages, ensure that it is not complicated, and treat it well so that the person can live a healthy life.

What Are Arterial Leg Ulcers?

Arterial leg ulcers are chronic and non-healing ulcers of the lower limbs caused by inadequate arterial circulation. Such ulcers arise when the blood supply carrying oxygen and nutrients to the skin of the legs and feet is cut off, causing damage and death of the skin tissues. They are, therefore, often linked with peripheral artery disease, more commonly known as PAD. In this condition, arteries get constricted or occluded by the atherosclerosis process, where the fatty materials are deposited on the walls of arteries.

Arterial leg ulcers are normally found in places with the most pressure, like the toes, ankles, or heels, and are usually small, round, and punched out in appearance. Because of inadequate circulation, the wound may have silky surgical margins and a colorless, dry, or gangrenous floor.

Difference Between Arterial and Venous Leg Ulcers

While arterial and venous ulcers form on the legs, their cause, location, and appearance differ.

• Arterial leg ulcers are caused by arterial blood circulation and atherosclerosis or other vascular diseases. These blisters usually develop on certain areas of the legs, such as the ankles, toes, or heels. Arterial ulcers are generally painful, especially when the legs are raised as blood struggles to flow up against gravity. These ulcers are typically small and, when circular, have a punched-out appearance with sharp margins.
• Venous leg ulcers are caused by the failure of valves, which leads to blood pooling and, hence, increased pressure in the veins. These ulcers are located on the medial aspect of the distal leg or anterior ankle and are more superficial and less painful than arterial ulcers. The wounds from venous ulcers are usually jagged, and the surrounding skin is swollen and discolored from inadequate venous flow.

The Role of Blood Flow in Arterial Ulcers

Arterial leg ulcer is a common clinical site that has been significantly associated with impaired blood flow. Blood vessels, particularly arteries, are vital structures because they transport oxygen and nutrients, which are the body's building blocks, contributing to the healing process of injured tissues and ensuring their integrity. The poor method of flow causes the blood to become stagnant and leads to the lack of oxygen and the eventual death of the cells in the body that is affected by the blockage of the arteries. Wound site lesions cannot be adequately supplied with blood and do not heal, or new ulcers develop. This is also why such ulcers are painful; the blood circulation to the surrounding area is very poor, and therefore, the tissues get an inadequate oxygen supply.

If there is inadequate blood circulation, even minor injuries or pressure points can transform into severe ulcers. Knowing more about blood flow, the formation of arterial leg ulcers is significant, so they can be treated early since treatments are usually based on the attempt to restore the blood flow in the affected area.

Causes of Arterial Leg Ulcers

Arterial leg ulcers are chiefly due to peripheral arterial disease, which affects blood vessels that supply blood to the lower limbs. When blood flow is slow or minimal, the tissues of the legs and feet do not receive the necessary nutrients and oxygen; therefore, they start to rot and form ulcers. The main predisposing factor for arterial leg ulcers is atherosclerosis, but several risk factors may worsen the disease and the probability of ulcer development.

Atherosclerosis and Poor Circulation

Arterial leg ulcers have more frequently been associated with atherosclerosis. It develops when fatty deposits called plaque accumulate on the artery walls, narrowing the blood vessels and reducing blood flow. If this happens over a while, it leads to the arteries becoming rigid, thus narrowing them even further so that blood can pass through. The units of blood flow decrease, and when the tissues do not receive adequate oxygen, they become weakened, die out, and become ulcers. If the affected tissue remains untreated, it is bound to degenerate and become necrotic, prolonging the healing rate.

Risk Factors for Arterial Leg Ulcers

Several risk factors contribute to the development of atherosclerosis and arterial leg ulcers:

Smoking: Arterial ulcer is one of the diseases that are influenced by the various risk factors one of them is smoking. Therefore, the tight chemical in cigarettes, including nicotine, reduces blood circulation by narrowing the arteries. Smoking also enhances the deposition of fatty material or plaque on the walls of arteries, leading to the rapid development of atherosclerosis. Besides, smokers are more likely to get peripheral artery disease (PAD), which often results in ulcers.

Diabetes: Arterial leg ulcers can be considered as a direct complication of diabetes since the vulnerability of the patients to the formation of these ulcers is twice as high. When a diabetic patient has raised blood sugar, blood vessels and nerves may get affected, leading to poor blood flow and slow healing. People with diabetes get neuropathy, which affects the feeling of the feet, and one can easily injure their feet and end up not knowing until it forms ulcers.

High Cholesterol: High cholesterol leads to a build-up of cholesterol in blood vessels, particularly in the arteries. If cholesterol levels are high, fatty deposits stagnate, leading to progressed blocks and increasing arterial leg ulcer risk. Cholesterol levels must, therefore, be controlled to avoid constriction of blood vessels.

Aging: As people age, their capacity to stretch and contract blood vessels diminishes, and the possibility of developing atherosclerosis increases. Some predisposing factors to arterial leg ulcers include older age, when people are likely to have poor blood circulation to the lower limbs. Also, changes in circulation and skin integrity associated with aging delay the rate at which ulcers heal; thus, their treatment becomes difficult.

Hypertension (High Blood Pressure): Because high blood pressure is prolonged, it eventually hardens and constricts the arteries. This leads to the formation of atherosclerosis and further narrowing of the arteries through which blood has to pass, which is likely to develop ulcers.

How Reduced Blood Flow Leads to Ulcer Formation

Decreased arterial circulation, for example, directly causes the formation of arterial leg ulcers. Whenever arteries are occluded or narrowed, the tissues in the lower extremities do not get the proper supply of oxygen and nutrients required to keep the skin and muscles healthy. This ischemia causes the tissues to lose their strength and become more vulnerable to injury.

An ulcer arises when there is a compromise in blood supply, even due to trivial trauma, pressure, application of minor injury, or even a slight cut. The wound can not heal without circulation, and the affected tissue begins to die. After some time, the skin over that region begins to get infected, which may lead to complications such as gangrene or even amputation at times.

Symptoms and Appearance of Arterial Leg Ulcers

Leg ulcers are arterial and usually accompanied by assigned symptoms and appearance that distinguish them from other ulcers. An insufficient blood supply typically causes them through the arteries; the look of these ulcers and the accompanying signs represent the effects of an inadequate supply of blood elements such as oxygen and nourishment in the affected skin tissues.

Common Symptoms of Arterial Leg Ulcers

Pain: The pain in arterial leg ulcers is severe and, therefore, considered one of the more obvious signs. This pain is usually described as throbbing and worsens at night or when the leg is raised because blood circulation to this organ reduces. This contrasts with venous ulcers, which are usually less painful. This discomfort may decrease when the leg is swung or is put in a position that will facilitate better free flow of blood towards the foot.

Coldness in the Affected Leg: Arterial leg ulcers are characterized by restricted blood flow, so the skin and tissues of the affected leg or foot will be cold. This coldness is accounted for because the blood can not circulate effectively to warm the tissues.

Discoloration: In some cases, the arterial ulcer is characterized by pale, bluish, or even black skin around the ulcer due to the shallowing of blood supply and, therefore, oxygenation. The discolored area is typically black or necrotic, indicating that the cells within this area have died—a characteristic feature of arterial leg ulcers. The toes or nails may also turn purple because of poor blood circulation.

Appearance of Arterial Leg Ulcers

The visual appearance of arterial leg ulcers can provide crucial clues for diagnosis. Several characteristics distinguish these ulcers:

Round, "Punched Out" Appearance: It is also essential to state that arterial leg ulcers tend to be round. In many cases, they have regularly refined edges and look ‘punched out’ from the tissue as if it were cut. This contrasts with venous ulcers, usually characterized by irregular and jagged margins.

Smooth and Pale Base: An arterial ulcer is characterized by a soft and pale color due to the absence of blood supply at the base. At times, the base of the lesion is dry, then sloughs and forms a black or brown scab known as eschar. In many cases, the ulcer bed shows little or no sign of granulation tissue, which are pink and bumpy tissues seen in healing areas suggestive of poor healing throughout due to inadequate blood supply.

Minimal Drainage: Unlike venous leg ulcers, which always have a lot of drainage, arterial leg ulcers are usually non-draining. This indicates that the affected part is not getting proper blood and nutrient supply; thus, the body's ability to produce the fluids needed for wound healing is minimal.

Location on the Legs: Arterial leg ulcers are usually found in the lower regions of the legs, where blood circulation is severely compromised. These ulcers tend to develop over pressure-sensitive areas on the body, including the ankles, heel, or toes. They regularly develop in body parts that can be exposed to some strain or an injury, such as the distal end of a toe or the lateral aspect of a leg area where blood circulation is poor. It's rare to see arterial ulcers higher up on the leg unless the arterial disease is exceptionally severe.

Diagnosis of Arterial Leg Ulcers

Properly identifying arterial leg ulcers is essential in treating and preventing their aggravation. Indeed, most of these ulcerations stem from inadequate arterial blood flow, so it is critical to get to the root of the issue to adequately address the wounds and the causes of poor blood flow. Failure to diagnose the disease makes it possible for the wrong treatment to be administered, with potential implications of slow healing, infection, and other complications that may lead to gangrene.

Importance of Accurate Diagnosis

Correct identification of arterial leg ulcers is possible and helps healthcare professionals distinguish them from venous or diabetic ones. A misdiagnosis could mean that the patient will be subjected to procedures that may worsen the ulcers, such as applying equipment that reduces blood flow to the affected area in the case of venous ulcers.

Accurate diagnosis helps in:

• Establishing a predicative course of treatment involves treating an ulcer and providing the patient with necessary circulatory support.
• It aims to minimize the possibility of getting infected again and also to avoid worsening of the tissues in my body.
• This includes preventing other possible complications; for example, limbing might be carried out in extreme situations.
• Secondary surveillance should be provided for other comorbidities, such as peripheral arterial disease (PAD), which is known to be related to arterial leg ulcers.

Several methods can quantify the degree of impaired blood flow to diagnose arterial leg ulcers. They assist in determining the extent of arterial obstruction, managing patients, and evaluating the effectiveness of treatment.

Ankle-Brachial Index (ABI):

• The ankle-brachial index (ABI) is one of the simplest and easiest noninvasive investigations to diagnose arterial leg ulcers. It measures the difference between the blood pressure of the ankle and the blood pressure of the arm. Researchers have proven that patients with lower ABI scores have less peripheral circulation in their lower limbs, and most arterial ulcers are caused by peripheral artery disease (PAD).

• ABI is performed using a blood pressure cuff and a Doppler ultrasound probe to detect blood flow. A normal ABI ranges from 1.0 to 1.4, while a result below 0.9 suggests significant arterial insufficiency. Severe cases with an ABI below 0.4 may indicate critical limb ischemia, which can lead to ulcer formation. 

Doppler Ultrasound:

• Another helpful diagnostic test for arterial leg ulcers is Doppler ultrasound. This noninvasive test uses sound waves to measure blood flow in the legs' arteries. It assists in identifying places with poor blood circulation due to the narrowing of the arteries or the buildup of plaque.
• However, Doppler ultrasound is sometimes used in conjunction with the ABI to make a definite diagnosis and visualize the location and degree of the arterial obstruction. The test can also help determine other problems with blood vessels, such as clots caused by poor circulation.

Angiography:

The other tactic is angiography, a more complicated and invasive test if the blockage's location and severity must be observed. This technique involves the injection of contrast dye into the arteries and using X-rays, CTs, or MRIs to provide a clear image of the blood vessels. Consequently, angiography helps define a location and the degree of arterial obstruction responsible for arterial leg ulcers. Typically, it is employed whenever revascularization is thought to be likely to be gained through angioplasty or bypass surgery to the area of the ulceration. There are also various kinds of angiography, such as digital subtraction angiography, magnetic resonance angiography, and computed tomography angiography, which all help visualize the arteries in detail regarding their condition.

Toe-Brachial Index (TBI):

In patients with calcified arteries, such as those with diabetes, the ABI test may give a wrong reading, more so because the arteries are rigid. In these cases, one may use the toe-brachial index (TBI), which is intended to evaluate blood pressure in the toes. It may give a more realistic view of blood flow through organs in small vessels.

Transcutaneous Oxygen Measurement (TcPO2):

The noninvasive test, including transcutaneous oxygen measurement (TcPO2), reveals the amount of oxygen supplied to the tissues and skin. It can prove useful in estimating the degree of ischemia in the concerned area and the prospects for wound healing. TcPO2 below 50 mmHg signifies low oxygenation, which is possible when leg ulcers are of arterial etiology.

Arterial Ulcer Treatment

Interventions to address arterial leg ulcers include treating the ulcer and its cause, such as poor blood circulation in the leg. A lack of blood supply causes these types of ulcers, and therefore, treatment involves more than just the actual ulcer but also circulation to the area. If left untreated, arterial leg ulcers can result in infection, gangrene, and, in some extreme circumstances, amputation.

Medications:

Antiplatelet drugs: Some patients are given drugs like aspirin or clopidogrel to prevent blood clots around the heart and enhance blood circulation.

Vasodilators: Other vasodilatory drugs, such as cilostazol or pentoxifylline, may also improve limb circulation.

Statins: These medicines have actions that reduce cholesterol levels and, therefore, slow the worsening of atherosclerosis, which is the primary factor contributing to poor blood circulation in patients with arterial leg ulcers. 

Surgical and Minimally Invasive Procedures:

Angioplasty: involves inflating a tiny balloon placed at the narrowed artery to open the blocked space. A stent—a small wire mesh tube—is usually inserted into it to prevent the artery from being blocked again. Proper blood circulation can enhance angioplasty and aid in healing ulcers.

Bypass Surgery: If angioplasty does not suffice, bypass surgery might be needed. This is performed by transplanting a healthy blood vessel obtained from another part of the body or by implanting an artificial vessel to go around the affected blood vessel, hence making a loop.

Endarterectomy is a surgical operation in which plaque buildup is cleared inside an artery to enhance blood flow.

Wound Care

Arterial leg ulcer care involves appropriate wound dressing, which is important in treating this condition. Because these ulcers take a long time to heal due to poor blood circulation, proper care is required so that they do not get infected and heal as soon as possible.

Keeping the Ulcer Clean: Cuts and scratches should be washed daily with water, antiseptic agents, or a normal saline solution since constant dirt accumulation will likely cause bacterial growth on the wounds.

Dressing the Wound: Adherence to the proper dressings protects the ulcer and creates the right moist environment, vital in wound healing. Emollient dressings that do not stick to the wound site (non-adherent dressings) are preferred, as expulsion of the dressing will not harm the sensitive tissue.

Debridement: Surgical procedures such as debridement—removing dead or necrotic tissues—are sometimes required. This can also be done through surgery or using dressings that reduce the volume of necrotic tissue present.

Infection Prevention and Treatment: The probability of getting infected in arterial leg ulcers is always high because of the lack of adequate blood circulation. If the ulcer becomes infected, it may manifest signs such as redness, swelling, increased pain, and pus formation, in which the doctor may prescribe antibiotics topical or oral.

Pain Management

These arterial leg ulcers may cause severe pain, chiefly because they are ischemic ulcers. In most cases, pain is likely aggravated when legs are raised and may get relieved when placed down in a dependent position.

Pain Relief Medications: Ibuprofen, for example, is an NSAID generally used in pain management, but more hard-core drugs, such as opioids, may be required in some instances. For example, topical analgesia should be administered at the ulcer site through patches or creams containing lidocaine.

Positioning: Some patients may be required to maintain the leg affected by the disorder at or below heart level to cure pain or to enhance blood circulation in the leg. However, the following should not place much pressure on the ulcerated area.

Lifestyle Changes

The risk of developing arterial leg ulcer relapse should be managed by eradicating the causes of poor blood circulation, generally related to lifestyle issues. Many risk factors that can lead to arterial ulcers can be prevented or managed through lifestyle changes, such as smoking cessation or improving one’s diet, to minimize the likelihood of getting additional ulcers in the future.

Quitting Smoking: reduces blood flow by narrowing the arteries and accumulating plaque in the arteries. Smoking cessation is one of the most critical and practical recommendations for patients in the therapies discussed to improve limb circulation and avoid the reappearance of arterial leg ulcers.

Controlling Diabetes: It is, therefore, paramount for any diabetic person to keep the blood sugar level to a desirable level to curb ulcer occurrence. Otherwise, the blood vessels and nerves wither, making them insufficient in supplying blood to the needed areas, often reaching for ulcers.

Improving Diet: Dieting low in saturated fats and cholesterol is the best way to prevent the further development of atherosclerosis. For better vascular health, it is recommended that one increase the consumption of fruits, vegetables, whole grains, and lean meats.

Managing High Blood Pressure and Cholesterol: Blood pressure and cholesterol must be well monitored to prevent arterial blockages. Some of these conditions require medication to be effectively controlled.

Importance of Addressing the Underlying Causes

Treating the ulcer is part of the procedure. Still, much focus should be placed on treating the issues causing inadequate blood circulation in a person’s lower extremities to avoid the reoccurrence of leg ulcers. Unless the predisposing conditions, which include atherosclerosis, diabetes, and smoking, are well controlled, there is a high chance that the patient will continue to develop new ulcers.

Prevention and Management of Arterial Leg Ulcers

Therefore, arterial leg ulcers must be prevented from developing or worsening because of properly tackling circulatory issues. Although these ulcers occur because there is inadequate blood supply to the arteries, there are measures that can be taken to prevent developing such ulcers and also measures that can be taken to prevent the ulcers from worsening once they have been formed. Prevention efforts aim to keep blood flow pumping well, control factors that can strain the circulation, and watch for signs that blood isn’t flowing as it should.

Tips for Preventing Arterial Leg Ulcers

Regular Check-ups and Monitoring of Circulatory Health:

• One of the most effective ways to prevent arterial leg ulcers is by regularly checking arterial circulation, especially for those at high risk, such as individuals with peripheral artery disease (PAD), diabetes, or a history of smoking.
• Healthcare providers can perform tests like the ankle-brachial index (ABI) or Doppler ultrasound to assess blood flow and detect signs of arterial insufficiency before ulcers develop.
• Monitoring foot and leg health is particularly important for individuals with diabetes or PAD. Even minor injuries, such as cuts or blisters, can lead to the development of an ulcer if blood flow is compromised. Early detection of circulation issues can prevent ulcers from forming or worsening.

Managing Risk Factors:

Quit Smoking: Smoking is one of the most significant risk factors for arterial leg ulcers as it constricts blood vessels and accelerates atherosclerosis. Quitting smoking is essential for improving blood flow and reducing the risk of ulcers.

Control Diabetes: Proper management of blood sugar levels in individuals with diabetes can help reduce the risk of nerve and blood vessel damage, which are significant contributors to arterial ulcers.

Maintain Healthy Cholesterol and Blood Pressure Levels: Controlling high cholesterol and hypertension is crucial in preventing the arterial blockages that lead to arterial leg ulcers. Medications like statins and blood pressure-lowering drugs can help manage these conditions.

Exercise: Regular physical activity like walking can improve circulation and help maintain healthy arteries. However, exercise programs should be discussed with a healthcare provider, especially for individuals with existing circulation problems.

Dietary Changes: A heart-healthy diet, rich in fruits, vegetables, whole grains, and lean proteins, can help reduce the progression of atherosclerosis. Limiting saturated fats and cholesterol is essential for maintaining healthy arteries.

Foot and Leg Care:

• Proper foot care is essential for preventing the development of arterial leg ulcers, especially for individuals with diabetes or PAD. Regularly checking the feet and legs for signs of injury, discoloration, or sores can help catch issues early before they develop into ulcers.
• Wearing comfortable, well-fitting shoes can prevent blisters and pressure sores that might become ulcers with poor blood flow. Avoiding tight shoes or socks that can reduce circulation is also essential.
• Keeping the skin moisturized helps prevent dryness and cracking, which can lead to wounds that may become ulcers if not correctly treated.

Avoiding Cold Temperatures:

• Cold weather can constrict blood vessels and reduce circulation in the extremities, increasing the risk of arterial leg ulcers. To keep the legs and feet warm in cold environments, it's essential to wear appropriate clothing and avoid direct exposure to cold air or water.

The Role of Compression Therapy in Arterial Leg Ulcers

Compression therapy involves applying pressure to the legs using specially designed socks or bandages. It is a standard treatment for venous ulcers but has limited use in arterial leg ulcers. Compression can further restrict blood flow to the already compromised arteries in people with arterial insufficiency.

Limited Use in Arterial Ulcers: Compression therapy should only be used cautiously and under the guidance of a healthcare professional in cases of arterial leg ulcers. If there is significant arterial disease, applying compression can exacerbate the problem by reducing blood flow even more, leading to further tissue damage and worsening the ulcer.

Combined Arterial and Venous Disease: Some patients may have both venous and arterial disease, which can complicate treatment. In these cases, mild or modified compression therapy may be considered, but only after thorough testing, such as an ankle-brachial index (ABI), to assess the extent of arterial insufficiency.

Preventing Ulcers from Worsening

Once an arterial leg ulcer has developed, taking steps to prevent it from worsening is critical to avoid complications such as infection, tissue death, or amputation. Key management strategies include:

Follow Wound Care Instructions:

• Keeping the ulcer clean and protected is crucial to preventing infection and promoting healing. Regularly changing dressings as directed by a healthcare provider helps maintain a healthy healing environment.
• Using specialized wound care products, such as non-adherent dressings, antimicrobial ointments, and wound care gels, can further support the healing process.

Keep Pressure Off the Affected Area:

• Reducing pressure on the area of the ulcer is vital for preventing further damage. Elevating the legs (while avoiding extreme elevation that restricts blood flow) and using protective footwear or padding can help relieve pressure on the ulcer site.

Promptly Address Any Signs of Infection:

• Poor blood flow, which limits the body's ability to fight off bacteria, makes infection a significant risk for arterial leg ulcers. Signs of infection, such as increased redness, warmth, swelling, or pus, should be addressed immediately with antibiotic treatment.

Conclusion

Arterial leg ulcers are severe conditions caused by poor blood flow due to arterial blockages. They are often linked to atherosclerosis, smoking, diabetes, and high cholesterol. Understanding arterial leg ulcers, their causes, and symptoms—such as pain, coldness, and ulcers with a "punched out" appearance—is crucial for proper diagnosis and treatment. Treatment options focus on improving circulation through medication or surgery, managing the wound to prevent infection, and making lifestyle changes to address underlying risk factors.

Early diagnosis and intervention are vital for improving outcomes and preventing complications like infection or tissue death. By addressing the root cause of poor circulation and following a comprehensive treatment plan, patients can improve healing and reduce the risk of future arterial leg ulcers.