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What is the difference between arterial and venous ulcers?

Chronic lower extremity ulcers can have several etiologies, and wound characteristics can be used to determine the cause of an ulcer.

How can we determine if an ulcer is due to venous insufficiency or arterial disease? 

History
Venous ulcers tend to have a rapid onset, are often due to trauma, and can be paired with lower extremity edema (swelling).

Arterial ulcers tend to progress slowly, and are commonly accompanied by arteriosclerosis (thickening and stiffening of the arteries), hypertension (high blood pressure), and intermittent claudication (pain/cramping in the legs caused by lack of blood flow which is relieved with rest).

If a patient has an extensive history of smoking, an arterial ulcer may be suspected.
 

What are the pain characteristics?
Patients with venous ulcers may have some pain which decreases with elevation of the lower limb due to the return of venous blood flow out of the lower limb.

Patients with arterial ulcers tend to have intermittent claudication pain, and pain tends to increase with elevation or exercise due to the lack of arterial blood flow. 

It is important to note that a venous ulcer is related to the pooling of deoxygenated venous blood that filters out of the venous compartment and cause tissue edema.  Arterial disease is related to a lack of arterialized blood, devoid of oxygen to the tissue.  The tissue is not swollen, but rather starving for oxygenated blood to heal traumatized tissue.  Walking, exercise dos not necessarily provide more oxygen because of the blockages (stenosis) in the arteries, and as such, can cause claudication (pain with exercise) or in its severe form, rest pain. 

Where is the ulcer located?

Venous ulcers are most commonly located in the following areas:

Medial malleolus (bony prominence on the inside of the ankle)
Ankle
Gaiter area of the leg
Lower calf

Arterial ulcers are most commonly located in the following areas:

Lateral malleolus (bony prominence on the outside of the ankle)
Anterior tibia (front of the lower leg)
Toes, heels, and bony areas of the foot

What does the ulcer look like?
Venous ulcers tend to have an irregular border and often have discharge. The skin surrounding a venous ulcer may be brown, thick, swollen, and blotchy.

Arterial ulcers tend to have a more defined border and are drier. The skin surrounding this type of ulcer may be thin, pale, cool, and may become red when the patient dangles their legs (dependent rubor).
 

Is infection common with arterial and venous ulcers? 
Venous ulcers tend to be colonized but there is less likely that there would be accompanying cellulitis or abscess formation in the underlying tissue.

Arterial ulcers can have mixed bacterial infections and can be associated with abscesses, especially in diabetics and more so in the plantar aspect of the foot.


Although venous versus arterial ulcers can be suspected based on appearance and pathophysiology, a vascular duplex ultrasound exam should be done prior to diagnosis to determine if the patient has venous insufficiency or lack of blood flow due to arterial disease.

Reference: Aydin, A., Shenbagamurthi, S., Brem, H. Lower Extremity Ulcers: Venous, Arterial, or Diabetic? Emerg Med J 2009; 41(8): 18-24.