The document discusses the epidemiology of chronic cutaneous ulcers, specifically leg ulcers and pressure ulcers in the United States. It finds that leg ulcers and pressure ulcers are common, but accurate data on their prevalence and costs within the US is lacking. While pressure ulcer rates in healthcare settings have been studied, national surveys are needed to obtain more precise figures. Risk factors for both types of ulcers are also discussed, such as immobility and age. Improved data collection is important for understanding the true impact of chronic ulcers.

1. CHRONIC CUTANEOUS ULCERS
Chronic Cutaneous Ulcers: Etiology and Epidemiology
TaniaJ. Phillips
Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts, U.S.A.
The most commonly encountered chronic cutaneous ulcers
in the United States are pressure ulcers and leg ulcers; this
review is limited to the epidemiology of these ulcers.
Chronic leg ulcers are frequently encountered in clinical
practice hut the extent of the problem is largely unknown. In
particular, epidemiologic information within the United
States is sadly lacking.
Although there are more data availahle regarding the inci-
dence and prevalence of pressure ulcers in acute and chronic
care facilities, national surveys should be considered to ohtain
more accurate information on their incidence and preva-
lence. Multicenter studies are necessary to determine the epi-
demiology and cost of treating pressure ulcers by stage, set-
ting, and other factors. Particular attention should be paid to
high-risk groups such as spinal cord injury patients, the el-
derly, and those who are immobilized or chronically debili-
tated.
Leg ulcers and pressure ulcers probably account for the
majority of chronic cutaneous ulcers seen in the United
States. Key words: cutaneous ulcers/epidemiology/etiology, f Invest
Dermatol 102:38S-41S, 1994
LEG ULCERS
Epidemiology With regard to leg ulcer epidemiology, there are
very little data available from the United States. In one widely
quoted paper [1], it is stated that 600,000 persons in the United
States suffer from chronic venous ulcers. However, the source for
this figure is not stated. Other authors estimate one-half million
cases of lower leg ulcers in the United States [2]. In a 1973 longitu-
dinal study of health and disease in a Michigan community [3] data
were extrapolated to 1970 census figures to give a rough estimate of
24 million U.S. citizens having varicose veins, 6-7 million having
stasis changes in the skin of the legs, and 400,000-500,000 having
a present or previous history of a varicose ulcer. Most data on leg
ulcer epidemiology have not come from the United States, but from
Europe. In 1956 in Sweden, Gjores estimated the prevalence of
active and healed leg ulcers as 6.4 per 1000 of population older than
15 years [4]. A study by Widmer of a population of industry workers
below retirement age sbowed a prevalence of 1% of active and
healed ulcers [5]. In a postal survey of tbe Lothian and Forth Valley
health districts with a population of about 1 million, Callam et al
found the prevalence of chronic leg and foot ulcers to be 1.48 per
1000 population. Cornwall et al [6] studied a regional health district
with a population of 198,900. Four hundred twenty-four leg ulcers
were documented, with an overall prevalence of 0.18%. In an epi-
demiologic study from Australia, a metropolitan population of
238,000 was screened for chronic ulceration of the leg. A preva-
lence 1.1 per 1000 population was found, with increasing preva-
lence with age. In this study, 93% of patients detected with leg
ulcers were fully assessed. Venous insufficiency was found in 57%.
Other etiologic factors, such as diabetes and rheumatoid disease,
were found in 36%. Significant arterial ischemia was present in only
5% of patients under the age of 70, whereas it was found in 31% of
those over the age of 70 [7].
In a Swedish study, Nelzen et al [8] performed a postal cross-sec-
tion survey with examination of a randomly selected sample of
reported patients. The median age was 78 years for women with leg
Reprint requests to: Dr. Tania Phillips, Boston University School of Med-
icine, Department of Dermatology, 80 East Concord Street, J-106, Boston,
MA 02118.
ulcers and 76 for men. Eighty-five percent of patients were older
than 64 years. The point prevalence for active leg ulcers was 3 per
1000 total population.
Prevalence data from all such studies are almost certainly an un-
derestimation of the true prevalence in the general population. This
is because all cases with ulceration are not reported and all reported
cases are not fully assessed. One problem of uncertain size is patients
with leg ulcers who are not known to the health care system. Most
of the surveys conducted in Europe relied on postal questionnaires
sent to inpatient and outpatient care services and hospitals, commu-
nity health care, private nursing homes, and visiting nurses.
Etiology Leg ulcers can have widely varying etiologies. How-
ever, the majority of leg ulcers in the Western world are due to
venous insufficiency, arterial insufficiency, or neuropathy (princi-
pally in diabetics). Traditionally, venous ulcers are thought to ac-
count for approximately 80 to 90% of cases; arterial disease accounts
for anotber 5 - 10%, and most of tbe others are due to neuropathy
(usually diabetic) or combinations of tbose diseases [9-11]. As the
population ages, the prevalence of leg ulcers is likely to increase and
the underlying etiology is likely to be altered with more mixed
venous and arterial disease and less pure venous disease.
In the middle of the 20th century several reports of patients with
leg ulcers stated a venous etiology in 84-97% [12-15]. However,
these studies were based on bigbly selected patients. Not until re-
cently have reliable estimates of causative factors been made [16,17].
Tbese were based on cross-sectional population samples and tbe
results show the presence of venous insufficiency in 76-81% and
arterial insufficiency in 21-31% of ulcerated legs. Both quoted
studies raised some methodologic questions. Callam [16] did not use
random selections, whereas Cornwall used this technique but noted
a substantial number of dropouts (33%) [6]. Nelzen eta/performed a
cross-sectional population study of leg ulcer etiology in Sweden
[18]. Three hundred eighty-two patients with active leg ulcers were
clinically examined after random selection out of a population of
827 patients identified within a previous cross-sectional population
survey. Bidirectional Doppler ultrasonography was used for objec-
tive assessment of arterial and venous circulation. Venous insuffi-
ciency was present in 332 (72%) of 463 legs witb active ulceration.
There was some element of arterial disease with ankle brachial
0022-202X/94/S07.00 Copyright © 1994 by The Society for Investigative Dermatology, Inc.
38S

2. V O L . 102, NO. 6, SUPPLEMENT, JUNE 1994 CHRONIC CUTANEOUS ULCERS 39S
iridex of 0.9 or less in 185 (40%) of ulcerated legs. Arterial insuffi-
ciency wasjudged to be the possible dominating factor in 12%, with
an additional 6% showing clearly as ischemic ulcers. Mixed ulcers
w i t h combined arterial and venous insufficiency occurred in 22%,
1 3 % occurred in diabetics, and in 10% no venous or arterial impair-
irient was detectable. Approximately 40% of all ulcerated legs
showed potentially surgically curable circulatory disturbances.
From more recent reports, it appears that there has been a change
in the etiologic spectrum of leg ulcer towards arterial and mixed
ulcers. In the middle of this century leg ulcers were generally
thought to be associated with venous insufficiency. It is probable
that arterial disease has increased because of changes in age distribu-
tion of the population and also due to improved diagnostic tech-
niques resulting in better detection of arterial disease. There are no
data available on the etiology of leg ulcers in the United States,
although, presumably, it would be similar to that in other countries
of the Western world.
C o s t of Leg Ulcers The cost of chronic non-healing wounds is
enormous. However, the cost of leg ulcers is almost impossible to
estimate, because the prevalence of the condition is not known and
estimates of the cost of treating leg ulcers vary widely. A study in
England analyzing the cost of dressing material using venous leg
ulcers estimated that the cost of 4 months of outpatient treatment
varied between $250 and $2500 [19]. Estimated annual costs of
ulcer treatment in Sweden are $25 million. Projecting these figures
to the U.S. population, costs would vary betweeti $775 million and
$ 1 billion [20]. O'Donnell et al in 1977 calculated that traditional
treatment of venous ulcers, including visits by a visiting nurse,
amounted to almost $40,000 per year per patient [21]. There is an
estimated loss of 2,000,000 work days annually in the United States
because of leg ulcers [22]. In a survey conducted in Boston (Phillips
et al, unpublished data), 42% of patients with leg ulcers who were
not working at the time of interview stated that their ulcer was a
factor in their decision to stop work. Patients who were working all
stated that the ulcer limited what they could do on the Job. The
rnorbidity and mortality from venous and arterial ulcers is not
known. With regard to diabetic patients, there is considerable mor-
bidity and mortality associated with ulceration of the lower limbs.
Patients with diabetes have been estimated to account for 45-70%
of all lower-extremity amputations performed [23-27]. The mor-
tality rate of diabetic amputees is high. Between 41% and 70% of
diabetics who experience leg amputation do not survive more than 5
years after the surgery [27-29].
Olcer Recurrence In several studies, the incidence of ulcer re-
currence is noted to be high, particularly in patients with venous
insufficiency [17,30,31].
In conclusion, chronic leg ulcers are frequently encountered in
clinical practice but the extent of the problem is largely unknown.
In particular, epidemiologic information within the United States is
sadly lacking. One problem is in choosing which population to
screen and how to adequately do so. Potential sources would include
hospitals, nursing homes, health maintenance organizations, visit-
ing nurse associations, dermatologists, vascular surgeons, and family
practitioners. However, this would still leave a pool of patients who
are caring for their own wounds. Some surveys have used advertis-
ing to facilitate self-referral, but this also has limitations. Once the
population can he identified, patients with leg ulcers would need to
be seen and have vascular studies performed to more precisely deter-
mine etiology. Most of the patients, or at least a very highly repre-
sentative sample, would need to be screened to give good estimates.
Most surveys to date seem to have relied on postal screening in
smaller metropolitan populations. This might be a good starting
point.
PRESSURE ULCERS
O n e problem when looking at the epidemiology of pressure ulcers
is differences in definitions as to what a pressure ulcer is. It is agreed
that pressure ulcers are localized areas of tissue necrosis that tend to
develop when soft tissue is compressed between a bony prominence
and an external surface for a prolonged period of time [32].
Some authors define blanchable and nonblanchable erythema as
early-stage pressure ulcers. However, such lesions are often not
reliably identifiable, especially in dark-skinned individuals. In addi-
tion, they have less clear-cut clinical implications [33]. A commonly
used classification scheme for pressure ulcers was described by Shea
[34]. Within this scheme grade I includes both erythema and an
epithelial defect; stage II, full-thickness skin ulcer extending to
underlying subcutaneous fat; stage III, full-thickness skin ulcer ex-
tending into subcutaneous fat but limited by deep fascia; stage IV,
penetration of deep fascia with extensive soft tissue spread, includ-
ing bone and Joint involvement. However, several other classifica-
tion schemes exist. In some of these, the earliest pressure sore that
might be defined as erythema developing over a pressure point
might be classified as blanchable or nonblanchable, or even further
defined as a mild persistent, moderate persistent, or severe persistent
erythema [35-43].
The types of data available on pressure ulcers are variable. As well
as variations in the definition of pressure ulcers, the composition of
study populations seems to vary. Some studies include all hospital
admissions, whereas others exclude certain groups such as pediatric,
maternity, and ambulatory surgical patients [32].
Acute Care Settings The prevalence of pressure ulcers reported
ranges between 3% and 14% among hospitalized patients in acute
care settings depending on the source of data, the inclusion of stage I
lesions, and the sample population [32]. Most studies report a range
of 3-11% [44-49]. The incidence of pressure ulcers among hospi-
talized patients in acute care settings appears to range between 1%
and 5% [32]. However, among hospitalized patients expecting to be
confined to bed or a chair for at least a week, the incidence is much
higher, at 7.7% within 3 weeks [45]. Most pressure ulcers develop
early during hospitalization [50,51]. Norton et al reported that 70%
of ulcers develop within thefirst2 weeks of hospitalization and that
patients on a geriatric unit in an acute care hospital develop a pres-
sure ulcer in 24% of cases. Similar findings have been reported by
others [51 -54]. If erythema is included in the definition of pressure
ulcers, then the incidence in acute-care hospital settings is higher
[33,49,55].
Long-Term Care Settings The prevalence of pressure ulcers in
nursing homes is not particularly higher than in acute care hospitals,
although they tend to have a large at-risk population [33]. There is a
high prevalence of pressure ulcers on admission ofpatients to skilled
nursing facilities (15-25%) [32]. The prevalence of pressure ulcers
tends to be higher among spinal injury patients than among patients
in nursing home or acute-care hospitals [33]. Young et al [56] re-
ported a 20-30% prevalence of pressure ulcers 1-5 years after
initial injury among patients followed in spinal cord injury' centers
in the United States.
Home-Care Settings Several studies [33,57] suggest that at least
60% of persons who have developed pressure ulcers develop them in
a hospital. About 18% develop them in the home and 18% develop
them in a nursing home. Within the home-care setting, the preva-
lence of pressure ulcers has been reported at between 7% and 12%
[32], with an incidence of at least 1.85% [57]. Approximately 70%
of pressure sores occur in patients over 70 years of age [58].
Risk Factors for Pressure Ulcers Immobility appears to be one
of the most important risk factors for the development of a pressure
ulcer [59,60]. Alhnan et al [45] performed a cross-sectional survey
that suggested that liypoalbuminenemia, fecal incontinence, and
the presence of a fracture may increase the risk of pressure ulcers
among immobilized patients in hospitals. Nutritional factors may
also be of importance [59]. A prospective study on pressure sore risk
among institutionalized elderly suggested that older age, low sys-
tolic and diastolic blood pressure, high body temperatures, and low
dietary protein intake were good predictors of pressure sore devel-
opment [61]. Other factors also play a role: in one prospective study

3. 4 0 S PHILLIPS THE JOURNAL OF INVESTIGATIVE DERMATOLOGY
incontinence caused a 5.5-times increase in the risk of a pressure
ulcer [62].
The available data confirm that pressure ulcers are primarily a
problem of older persons. A study of risk factors by Guralnik et al
[57] suggests that persons 70-75 years of age have a nearly twofold
higher incidence of pressure ulcers than persons 55 to 69 years of
age. Other risk factors found in this study were self-assessed poor
health, dry or scaling skin (on physical examination), cigarette
smoking, and inactivity.
Cost of Pressure Ulcers Without knowing the precise inci-
dence of prevalence of pressure ulcers, it is impossible to predict
their total national cost. Estimates of average per-case financial cost
of pressure ulcer treatment in acute care settings range widely, from
approximately $2,000 to $30,000. The lower estimates are typically
for cases in which pressure ulcer is not the primary diagnosis [32]. In
many cases, hospital costs reflect total patient care, including man-
agement of chronic illness, which is likely to predispose to ulcer
formation. Thus, the specific cost of ulcer treatment is difficult to
separate [32]. It has been estimated that within the United Kingdom
the cost of pressure sore treatment by the National Health Service is
£150,000,000 ($2-3,000,000) per year. A full-thickness sacral
pressure ulcer may extend hospital stay by over 25 weeks at an
estimated cost of $40,000 [58].
Morbidity and Mortality of Pressure Ulcers Pressure ulcers
are associated with a variety of complications including infection
and bacteremia [33,63,64]. Sugarman reported that osteomyelitis
occurs in 26% of non-healing pressure ulcers [65]. Pressure ulcers
are associated with increased risk of death and prolonged hospital-
ization.
In one study pressure ulcers were associated with a fourfold risk of
dying [33]. Pressure ulcer patients tend to be hospitalized for longer
than patients without pressure ulcers [45].
In summary, although there are some data available regarding the
incidence and prevalence of pressure ulcers in acute and chronic care
facilities, national surveys should be considered to obtain more ac-
curate information on their incidence and prevalence. Multicenter
studies are necessary to determine the epidemiology and cost of
treating pressure ulcers by stage, setting, and other factors. Particu-
lar attention should be paid to high-risk groups such as spinal cord
injury patients, the elderly, and those who are immobilized or
chronically debilitated [32].
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