Skin ulcerations. In the healthcare field, it’s a condition that can spark worry in a medical team, feel painful for patients, and be terrifying for families. The term brings to mind the image of bedsores, possibly caused by neglect and abuse. But, anyone who has a loved one in a healthcare facility should understand that not all ulcers are the same—and, perhaps somewhat reassuringly, most are not the result of negligence. Ulcers can and do happen, even in the presence of excellent clinical care.

There are a variety of skin ulcers. Most people are somewhat familiar with decubitus ulcers, more commonly known as pressure sores (and also sometimes called bedsores). Kennedy Terminal Ulcers (KTUs), another type of pressure sore, occur at the end of life. There are several other types of ulcers that are not pressure-related, including venous stasis ulcers, neurotrophic (diabetic) ulcers, and arterial ulcers.

Unlike pressure ulcers, arterial ulcers are due to poor blood circulation, which can occur acutely (such as with trauma or thrombosis) or chronically (such as with atherosclerotic disease). Arteries deliver nutrient- and oxygen-rich blood to the body. When blood flow is restricted due to arterial disease or damage, tissue in the area begins to die, resulting in ulceration. In some cases, lack of blood flow prevents ordinary scrapes or cuts from healing, eventually resulting in open ulcers. Regardless of whether the wound originates internally (e.g., tissue starvation or tissue death) or externally (e.g., a cut or scrape that won’t heal), the root cause is found at the vascular level.

Four Factors for Identifying Arterial Ulcers

Besides their root cause, there are several characteristics that will help to identify arterial ulcers.

• LOCATION: Arterial ulcers usually occur on the tips of toes, between toes, and on heels or outer ankles where boney prominences may rub against surfaces, such as shoes or bed sheets.
• APPEARANCE OF WOUND: Arterial ulcers have even borders that appear to be punched out, with even, well-defined borders. They are typically very deep, sometimes exposing underlying tendons. The wound base is dry and pale, with an absence of bleeding. The tissue may be necrotic (appearing yellow, brown, gray or black) and often shows no sign of new tissue growth.
• APPEARANCE OF EXTREMITY: The affected extremity will be cool or cold to the touch, may lack a palpable pulse, and may show signs of hair loss. The skin will likely be shiny, thin, dry, or taut. Another visual clue is the color of the extremity itself: if it is red when dangled, but turns pale white when elevated, this could indicate a problem with blood flow, meaning the ulcer may be arterial in origin.
• TESTING: Vascular studies may also be used to determine arterial insufficiency. These include performing an ankle brachial index, arterial Doppler transcutaneous oxygen delivery (TcPO₂), and toe pressures and arteriography.

Best Practices for Treating Arterial Ulcers

Once diagnosed, arterial ulcer treatment choices are limited and will vary depending on the severity of the underlying disease. The main goal of treatment is to improve blood flow to the area. For this reason, compression dressings—a traditional wound treatment—are contraindicated for arterial ulcers because they further restrict blood flow. If the wound is dry, it should be kept dry. If the wound is moist and open, a non-occlusive dressing may be indicated. For arterial wounds with infection, conservative debridement may be used. Traditional wound debridement is not the first choice for treatment as it can worsen arterial ulcers. Pain management should also be part of the treatment plan, as arterial ulcers tend to be quite painful.

For some patients, treatment may go beyond the local wound site. Surgical interventions may be considered in order to restore blood flow to the affected areas. However, many patients with advanced atherosclerotic disease who have multiple comorbidities will not be candidates for surgery other than above-the-knee amputation.

Preventing Future Arterial Ulcers

Overall, the standards of care for arterial wounds require implementation of treatments as ordered; promotion of blood flow to the affected areas; and daily monitoring for signs and symptoms of infection or worsening wounds. Lifestyle changes are recommended to improve blood flow and prevent future wounds, including smoking cessation, avoiding constrictive clothing or shoes, and avoiding cold temperatures. Persons with arterial insufficiency should be vigilant in preventing trauma to the area, which may cause additional wounds. Nutrition is also important to aid in healing and prevention.

Arterial ulcers can be alarming, just like bedsores and other types of wounds. But with an understanding of their physiological cause and possible interventions, providers and families can work together to find the best treatment and achieve the best outcome for patients. When it comes to skin ulcers, knowing the facts and documenting the care that’s been provided can help alleviate emotional upset and prevent unnecessary claims and allegations—a win for everyone involved.