Patients
with chronic venous disease (venous insufficiency) develop changes in the foot,
ankle and leg. They develop varying degrees of varicose veins, skin
pigmentation, thickening of the skin and subcutaneous tissues and ulceration in
the ankle region. Skin thickening and
nodular formation mimics cellulitis in many patients and there is a possibility
that many of them may receive antibiotics for control infection and cellulitis.
The thickening of the skin and subcutaneous tissues in chronic venous disease
usually occurs on the medial side of the leg. Skin pigmentation is common and
it is rare to see the induration and thickening on the medial side without skin
pigmentation. It is still not clear which factors will
determine the development of the thickness of the tissues ( Lipodermatosclerosis)
and the speed at which they develop in a given patient. We have seen this symptom
Lipodermatosclerosis in people who are obese and non-obese, who are tall and
short. It may not be uncommon to see a obese man with inverted champagne bottle
like legs in vascular surgery clinics. The indurated, sclerotic plaques with a
“bound-down” appearance (ie, they appear as if tethered—or bound—to the
subcutaneous tissue) affecting the skin from below the knee to the ankle is
common in our clinics in patients who had chronic venous disease for more than
10 years with or without history of DVT. Usually there is a sharp demarcation
between affected and unaffected skin. It
is proposed that venous reflux leads to increased venous pressures which can
result in extravasation of interstitial fluid and red blood cells, decreased
diffusion of oxygen to the tissues, and eventual tissue and endothelial damage.
As the endothelium is damaged, microthrombi formation and infarction ensue,
stimulating fibroblasts to form granulation tissue. Fibroblast might be playing a major role in
progression of the fibrotic reaction in the ankle and leg region. The dilated veins
are palpable in this scar like tissues and sometimes they may be source of
profuse bleed from the ankle region. When such a bleed occurs one would be concerned
about further bleeds from the leg. Sclerotherapy may help to stop the bleed and
heal ulcers. But patients would certainly like to get it excised completely and
get skin grafting if possible.
Lymph generated from the ankle joint complex causes inflammation of down stream segment, including veins, adipose and other subcutaneous tissue components, and knee and hip joints. Inflammatory reaction can be easily triggered by the slaengh food, which is of animal origin. Stasis ulceration, osteoarthritis, and idiopathic osteonecrosis are some products of the pathognomy.
ReplyDeleteTreat the ankle with appropriate care and drain the lymph of the leg properly, all pathology therein is soothed and healed.
Wichai Ekataksin, M.D., Ph.D.
Professor of Lymphology
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