Experience | Leaflets | Patient+ | News | Products | Other
This is a PatientPlus article. PatientPlus articles are written for doctors and so the language can be technical. However, some people find that they add depth to the articles found in the other sections of this website which are written for non-medical people.
Venous Leg Ulcer
Post your experienceVenous ulcers are usually large, shallow, painless and situated around the medial or lateral malleoli. They are associated with other signs of venous hypertension such as varicose veins, varicose eczema, haemosiderin pigmentation, atrophy blanche and venous flare. Oedema of the lower leg may be present and chronic venous stasis can lead to warty hyperplasia of the skin or thickening of the subcutaneous tissues.
Venous ulcers are caused by incompetent valves in the veins of the lower leg, especially in the perforators. These incompetent valves cause blood to be squeezed out into the superficial veins, when the calf muscles are contracted, instead of upwards towards the heart. Dilation of superficial veins occurs (varicosities) and the subsequent raised venous pressure results in oedema, venous eczema and ulceration. Valves may also become damaged following the venous hypertension that occurs in pregnant women and there may be congenital absence of valves.

The prevalence in the UK is 1.5-3 per 1,000. It increases with age and reaches 20 per 1,000 in the 80 plus age group.1
The diagnosis is usually made clinically.
History
The following history may suggest venous ulceration:2
- Pre-existing varicose veins
- Deep vein thrombosis
- Phlebitis
- Previous fracture, trauma or surgery
- Family history of venous disease
- Symptoms of venous insufficiency: for example, pains or heaviness in the legs, aching, itching, swelling, breakdown of the skin surface, pigmentation, eczema
Features in the history which suggest a non-venous cause include:
- Family history of non-venous ulcers
- History of:heart disease, stroke, transient ischaemic attack
- Diabetes mellitus
- Peripheral vascular disease or intermittent claudication
- Cigarette smoking
- Rheumatoid arthritis.
Examination
80% of all leg ulcers are venous ulcers and a large shallow relatively painless ulcer with an irregular granulating base in the 'gaiter' region of the leg (between the knee and ankle) is likely to be venous in origin.3 There may be surrounding stasis dermatitis.
Examination can help to rule out a number of differential diagnoses, as follows:
- Arterial ulcer - look for reduced pulses in the foot, ankle and possibly femoral artery. These ulcers occur most commonly in areas of poor blood supply, e.g tip of toes or over the tibia and are typically painful and deep. Other evidence of poor blood supply may include peripheral cyanosis and claudication.
- Neuropathic ulcer - this is painless, deep, often with overlying hyperkeratosis and occur at sites of loss of nerve supply and recurrent trauma, i.e. heel, metatarsal heads.
- Malignancy - malignant ulcers in this area are rare but the possibility should not be overlooked. Watch out for an ulcer with a rolled everted edge. If ulceration occurs in the area of scar tissue, Marjolin's ulcer should be considered.4 Chronic venous ulcers can develop into malignant ones, so any non-healing ulcer should be referred for biopsy.
- Rheumatoid ulcer - these look a bit like arterial ulcers and are sharp, deep, well-demarcated ulcers with a punched out appearance. They occur typically on the dorsum of the foot and calf, and may be slow to heal. Venous ulcers also occur in rheumatoid patients, so the differentiation may be difficult. It is, however, worthwhile referring suspected rheumatoid ulcers to a rheumatologist, as such ulcers often respond well to a disease-modifying anti-rheumatic drug (DMARD).
By the very nature of epidemiology, the patient may be elderly, frail and with reduced mobility and investigations in these circumstances may be limited. Primary care clinicians are advised to liaise with local community services to see what is available. Skilled nurses may well be able to carry out at least some of these investigations in the community.
SIGN guidance recommends:5
- Measurement of ankle brachial pressure index (ABPI) using Doppler - this is to exclude an arterial ulcer.6 A blood pressure cuff is applied to the lower calf muscle just above the ankle. A Doppler ultrasound probe is placed over the dorsalis pedis artery. The maximum cuff pressure at which a pulse can be heard is then recorded. The figure is then expressed as a ratio of the systolic pulse measured at the brachial artery. An index of 0.80 or less suggests significant peripheral arterial disease. In these cases, SIGN recommends referral to a vascular specialist.
- Measurement of the surface area - this gives an indication of rate of healing or failure to progress.
- Swabs for microbiology - this is only necessary if there are clinical signs of infection such as cellulitis.
- Patch testing - if there is associated dermatitis, chronic ulcer patients should be referred for patch testing using what is known as the 'leg ulcer series'. This is a group containing the kind of allergens to which a leg ulcer patient would be exposed, e.g. chemicals contained in leg ulcer dressings.
- Biopsy - if the ulcer has an atypical appearance or fails to heal after twelve weeks of active treatment.
- Graduated compression - before this treatment is tried, diabetes, neuropathy and peripheral vascular disease should be excluded and pre-existing swelling controlled by bed rest or elevation. The treatment involves applying bandages to the leg, maximising the pressure at the ankle and gaiter area and reducing the pressure as one goes higher up the leg. This helps to control or reverse venous insufficiency. There are many options available in terms of types of dressing, number of layers and whether to use elasticated or non-elasticated bandages. For uncomplicated venous ulcers, SIGN recommends an elasticated multi-layer dressing (wool padding, dressing to keep padding in place, elasticated bandage and outer cover). This approach was confirmed by a recent Cochrane review.7
- Debridement and cleaning - adherent slough should be debrided and any trapped pus released. Somewhat surprisingly, a randomised study found that cleaning traumatic soft tissue wounds with tap water resulted in a lower rate of infection than if sterile saline was used.
- Dressing - the treatment of choice for most vascular ulcers is an occlusive hydrocolloidal dressing which allows for epithelial cell migration and the influx of leucocytes and moisture.8 Topical growth factor has also been used to promote healing.
- Antibiotics - these are not indicated for uninfected ulcers.9 If there is clinical suspicion of infection, e.g. the presence of cellulitis, a swab should be taken and oral antibiotics instituted. Topical antibiotics can cause sensitivity and there is no place for them, except for metronidazole gel, which may be useful for malodorous ulcers.
- Topical steroids - a moderately potent steroid, e.g. clobetasone, may be helpful in treating surrounding venous (stasis) dermatitis. Persistent dermatitis which fails to respond to treatment suggests an iatrogenically-induced allergy and is an indication for patch testing.
Better results can be expected if the patient is mobile, able to walk and has no significant co-morbidities.
Referral is indicated in the following situations:
- Diabetes mellitus
- Peripheral arterial disease (ABPI <0.8)
- Rheumatoid ulcer
- Suspicion of malignancy
- Atypical distribution of ulcers
- Dermatitis resistant to topical steroids
- Patients who may benefit from venous surgery or skin grafting
- Failure to progress (especially in patients with significant co-morbidity10
Intermittent pneumatic compression11
A Cochrane review found that this improved healing, but further work is required to establish whether it should be used as an adjunct to compression bandaging or instead of this treatment.
Venous surgery
This is indicated in the following situations:3
- Patient fit for surgery (local anaesthesia if necessary)
- Sufficient mobility to activate calf muscle pump
- Prepared to attend hospital for investigation and surgery
- Obesity controlled (body mass index <30)
- Superficial venous incompetence: no deep venous incompetence on duplex imaging, or predominantly superficial venous incompetence on ambulatory venous pressures with tourniquet occlusion of the superficial veins
Skin grafting
Pinched skin grafting may be indicated in patients with extensive areas of ulceration. This has been done successfully by nurses in the community who have been trained in the technique.3 Bilayer artificial skin used with compression bandaging has been shown to be helpful.12 For complicated ulcers, artificial dermis combined with a thin skin graft has shown promising results.13
Primary prevention of venous insufficiency
Avoidance of prolonged standing or sitting, control of risk factors, e.g. obesity, and use of compression hosiery when early signs of venous insufficiency, e.g. stasis dermatitis, can all help to prevent the development of ulcers.14
Secondary prevention of a recurrent ulcer
- Correctly fitted compression hosiery should be worn for five years after an ulcer.
- Underlying co-morbidities, e.g. diabetes, rheumatoid arthritis, should be managed appropriately.
- Vascular surgery should be considered if the patient fits the criteria (see above).
Document references
- Clinical Knowledge Summaries; Leg ulcers - venous 2008.
- The nursing management of patients with venous leg ulcers, Royal College of Nursing (2006)
- Simon DA, Dix FP, McCollum CN; Management of venous leg ulcers. BMJ. 2004 Jun 5;328(7452):1358-62.
- Chong AJ, Klein MB; Images in clinical medicine. Marjolin's ulcer. N Engl J Med. 2005 Mar 10;352(10):e9.
- SIGN Publication No. 46; The care of patients with chronic leg ulcers. A national clinical guideline. July 1998.
- Ruff D; Doppler assessment: calculating an ankle brachial pressure index. Nurs Times. 2003 Oct 21-27;99(42):62-5. [abstract]
- O'Meara S, Cullum NA, Nelson EA; Compression for venous leg ulcers. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD000265. [abstract]
- Paletta C; Vascular ulcers. eMedicine, 2008.
- Hirschmann JV; When antibiotics are unnecessary. Dermatol Clin. 2009 Jan;27(1):75-83. [abstract]
- Anderson I; Mixed aetiology: complexity and comorbidity in leg ulceration. Br J Nurs. 2008 Aug 14-Sep 10;17(15):S17-8, S20-3. [abstract]
- Nelson EA, Mani R, Vowden K; Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD001899. [abstract]
- Jones JE, Nelson EA; Skin grafting for venous leg ulcers.; Cochrane Database Syst Rev. 2005 Jan 25;(1):CD001737. [abstract]
- Canonico S, Campitiello F, Della Corte A, et al; The use of a dermal substitute and thin skin grafts in the cure of "complex" leg ulcers. Dermatol Surg. 2009 Feb;35(2):195-200. [abstract]
- Feied C, Weiss R, Hasheyimoon R; Venous Insufficiency eMedicine.com 2009.
Internet and further reading
- Persoon A, Heinen MM, van der Vleuten CJ, et al; Leg ulcers: a review of their impact on daily life.; J Clin Nurs. 2004 Mar;13(3):341-54. [abstract]
- Renner R, Gebhardt C, Simon JC, et al; Changes in quality of life for patients with chronic venous insufficiency, present or healed leg ulcers. J Dtsch Dermatol Ges. 2009 Apr 6. [abstract]
Document ID: 4099
Document Version: 23
Document Reference: bgp26025
Last Updated: 7 Aug 2009
Planned Review: 7 Aug 2011
The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest. Find out more about updating.
Patient UK Hearing Impairment Survey
Patient UK are grateful to the 550 people who took part in this survey.
To see the results click here.
If you'd like to leave your feedback, please go to our interactive forum.
Related pages in Patient UK
Your Experience (^ top of page)
Please add your experience about this condition / medicineHealth Topic information leaflets related to this topic (^ top of page)
Malignant Skin Ulcers
Venous Leg UlcersPatientPlus articles related to this topic (^ top of page)
Leg Ulcers
Varicose Eczema
Varicose VeinsPatient UK Newspaper (^ top of page)
Latest Health News
View current health newsRelated Products (^ top of page)
Medical equipment

Books

Other - Useful resources (^ top of page)
Pictures, diagrams, photos, images, etc.Evidence based medicine
Online textbooks and journals
UK Guidelines
Online Videos
Medline
Other good health sites
Want to search some more? Use the Google Search box below to search our site.
Disclaimer: Patient UK has no control over the content of any external links above. Inclusion does not imply endorsement by Patient UK.
Want to advertise on this site? Find out how >>
Here you can follow a link to view existing patient experiences on this subject, or to add your own
This will offer you the usual PDF options i.e. document navigation, search, zoom and formatted print
Note: this is the best way to print the document
Note: this will open in a new window
Note: this will open in a new window
Here you can follow a link to view existing patient experiences on this subject, or to add your own
This will offer you the usual PDF options i.e. document navigation, search, zoom and formatted print
Note: this is the best way to print the document
Note: this will open in a new window
Note: this will open in a new window




