Venous leg ulcer

A leg ulcer is a long-lasting (chronic) wound on your leg or foot that takes more than six weeks to heal.

Information written and reviewed by Certified Doctors.

Contents

Introduction

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A leg ulcer is a long-lasting (chronic) wound on your leg or foot that takes more than six weeks to heal.

The symptoms of a venous leg ulcer include pain, itching and swelling in the affected leg. There may also be other signs, such as discoloured or hardened skin around the ulcer.

You should see your doctor if you think you may have a venous leg ulcer as they will not heal on their own. Your doctor will examine your leg and may carry out additional tests to rule out other conditions.

Read more information about how a venous leg ulcer is diagnosed.

What causes a venous leg ulcer?

A venous leg ulcer is the most common type of leg ulcer, accounting for 80-85% of all cases. Venous leg ulcers develop when persistently high blood pressure in the veins of the legs (venous hypertension) causes damage to the skin, which eventually breaks down and forms an ulcer

Read more information about the causes of a venous leg ulcer.

Who is affected?

You are more at risk of developing a venous leg ulcer if you:

Treating venous leg ulcers

With treatment, 70% of small ulcers will heal within 12 weeks. Larger ulcers may take longer to heal. Treatment usually involves cleaning and dressing the wound and using compression bandages to control blood pressure inside the legs.

However, unless underlying risk factors such as immobility, obesity and varicose veins are addressed, there is a high risk of a venous leg ulcer reoccurring.

Leg ulcers are commonly colonised by many types of bacteria. However, bacteria are not the cause of the ulcer and do not need to be treated unless there is an obvious infection. Antibiotics have no effect on healing the ulcer, so are not part of routine treatment.

Read more information about treating venous leg ulcers.

A venous leg ulcer can also lead to several complications, including a loss of mobility and the risk of infection. In rare cases, infection could lead to more serious conditions such as osteomyelitis or blood poisoning (sepsis).

Read more information about complications of venous leg ulcers.

Can venous leg ulcers be prevented?

There are several ways to help prevent a venous leg ulcer, such as wearing a compression stocking, losing weight if you are obese, and taking care of your skin.

This is particularly important if you have previously had a leg ulcer, as once a leg has suffered a venous ulcer, there is a one in four chance of further ulcers developing within two years.

Read more information about preventing a venous leg ulcer.

Symptoms

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A venous leg ulcer is a chronic non-healing wound with broken skin and exposed tissue.

Venous leg ulcers are usually found on the inside of the leg, just above the ankle. They are often painful, particularly when infected (see below). However, with correct treatment the pain can often be resolved.

If you have a venous leg ulcer, you may also have:

  • swollen ankles filled with fluid that temporarily hold the imprint of your finger when pressed (known as pitting oedema)
  • discolouration and darkening of your skin around the ulcer (known as haemosiderosis)
  • hardened skin around the ulcer, which may make your leg feel hard and resemble the shape of an upside-down champagne bottle (known as lipodermatosclerosis)
  • small, smooth areas of white skin, which may have tiny red spots (known as atrophie blanche)

The associated symptoms of a venous leg ulcer are caused by blood not flowing properly through your veins. This is known as venous insufficiency, and can cause:

  • leg pain, which can be continuous or may come and go
  • a heavy feeling in the affected leg
  • aching
  • itching
  • swelling
  • varicose eczema (itchy, irritated skin associated with varicose veins)

Infection

A venous leg ulcer can be vulnerable to bacterial infection. Symptoms of an infected leg ulcer include:

  • worsening pain
  • a high temperature of 38ºC (100.4ºF) or above
  • a painful, tender red region developing rapidly around the ulcer

When to seek medical advice

You should always contact your doctor if you think you have developed a venous leg ulcer. Venous leg ulcers are unlikely to get better on their own. They require specialist medical treatment.

Read more information about how venous leg ulcers are treated.

Causes

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A venous leg ulcer is caused by low blood circulation due to damaged veins in your legs.

There are two main types of blood vessel:

  • arteries – oxygen-rich blood is pumped from your heart, through your arteries, to the rest of your body
  • veins – blood is returned to the heart through the veins once the oxygen has been removed

Vein problems occur when the valves inside the veins stop working properly.

In a healthy vein, blood flows towards the heart. Blood is prevented from flowing backwards by a series of valves that open and close to let blood through. If the valves weaken or are damaged, for example, following a deep vein thrombosis, the blood can flow backwards.

This may cause varicose veins visible on the surface of the leg, or the damage may lie in the deep veins, hidden from view. Pressure inside these veins is increased and this can damage the skin.

The constant high blood pressure in your legs causes fluid to leak from the veins. The fluid causes swelling and damages the skin, which becomes hard and inflamed, leading to an ulcer.

Risk factors

Risk factors for developing a leg ulcer include:

  • obesity – this increases your risk of high blood pressure, which can damage the veins in your legs
  • being immobile for a long period – this can lead to a weakening of the calf muscle
  • deep vein thrombosis (DVT) – blood clots that develop inside the leg, which can damage valves inside the veins
  • varicose veins – swollen and enlarged veins caused by malfunctioning valves
  • previous injury to the leg, such as a broken or fractured bone, which may cause a deep vein thrombosis
  • diabetes – due to poor blood circulation and an increased risk of pressure ulcers
  • increasing age – generally, the older you get the less efficient your blood circulation system becomes
  • peripheral arterial disease – blocked arteries in the legs, most commonly caused by smoking

Diagnosis

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See your doctor if you think you may have a venous leg ulcer. A venous leg ulcer is diagnosed based on your symptoms and a physical examination of your affected leg. Additional tests may also be required.

Your doctor or nurse will first perform a physical examination on your leg when you are standing and when you are lying down. Varicose veins will be more obvious when you are standing and it will be easier to look at the ulcer when you are lying down.

They will look for symptoms of a venous leg ulcer, such as severe skin damage arising from venous disease (lipodermatosclerosis) and dark pigmentation of the skin near the ulcer due to vein problems. They will feel your pulse at your ankles to make sure the arteries in your leg are working properly.

Your doctor or nurse may also try to determine the cause of the ulcer by asking you about any underlying conditions you may have, such as diabetes or deep vein thrombosis (DVT), and any previous injuries, ulcers or surgery you may have had on your affected leg.

Doppler study

To rule out a condition affecting your arteries (vessels that carry blood from your heart to the rest of your body), your doctor or nurse will carry out a test known as a Doppler study to check for peripheral arterial disease.

The test involves taking a measurement of your blood pressure in each leg, at the ankle, and comparing it with the blood pressure in your arm. The arterial blood pressure should be about the same in the arms and legs. Peripheral arterial disease is diagnosed when the blood pressure in the legs is reduced compared to that in the arm.

It is important to check the arterial system because if severe arterial disease is causing a leg ulcer, urgent treatment is needed to restore blood flow to the leg. If this is not done, gangrene of the leg may occur. Bandaging a leg with arterial disease, a common treatment for venous leg ulcers, reduces the blood flow further and may make the ulcer much worse.

You may also be referred to a vascular specialist if your doctor or nurse is unsure about your diagnosis, or what has caused your leg ulcer.

A vascular specialist may arrange for a colour duplex ultrasound scan to be done. This allows measurement of blood flow in the veins and arteries of the leg so that venous valves can be assessed and arteries checked. This will tell the specialist which blood vessels are damaged or blocked and how this should be treated.

Read more information about how venous leg ulcers are treated.

Treatment

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A venous ulcer can be healed by either applying strong sustained compression with a bandage or a stocking, and by treating the underlying cause of the ulcer. When appropriate, both treatments can be used at the same time.

Following the advice below may help your venous leg ulcer heal more quickly:

  • Try to keep active by walking regularly. Immobility can make venous leg ulcers and the associated symptoms, such as oedema (swollen, fluid-filled areas), worse.
  • Whenever you are sitting or lying down, try to keep your affected leg elevated.
  • Be careful not to injure your affected leg, and wear only comfortable well-fitting footwear.
  • If you are prescribed an emollient by your nurse for venous eczema, use it as often as possible. The motion of rubbing in the emollient boosts your circulation and there is no limit to how often you can use it.
  • Wear your compression bandage exactly as instructed by your nurse. If you have any problems with it, do not remove it yourself.

The specific treatment options are described in more detail below.

Compression treatment

Application of a firm compression bandage or a graduated elastic medical compression stocking to a leg with a venous ulcer is one of the most effective methods of treatment. This will lead to about 70% of ulcers healing within six months.

Before starting compression treatment, it is essential that a Doppler test is used to measure the ankle and arm blood pressures to make sure the arteries are working normally in the leg. Gangrene may result from the use of compression treatment in patients with severe peripheral arterial disease in the leg.

Graduated elastic medical compression stockings can be used by patients with reasonable strength in their hands, since they can be a little difficult to put on. Modern systems are available that contain two stockings; both are worn on the ulcerated leg during the day and one is removed at night. These are easier to use than one heavy stocking.

Ulcer dressings (see below) can be applied after removing both stockings. Many patients find they can manage this themselves.

There are many different types of bandage used to treat venous leg ulcers. Some use just one type of bandage, while others are made up of several layers. The application of a compression bandage is a skilled procedure and should be done by a healthcare professional trained in leg ulcer management.

Bandaging of the leg is usually done after a leg ulcer dressing change. The bandage and ulcer dressing can then remain in place for up to a week, depending on how often ulcer dressing changes are required.

Ulcer dressings

The aim of applying a dressing to an ulcer is to provide conditions for the ulcer to allow healing. It has been found that the actual dressing type that is used does not influence how quickly the ulcer heals.

The first stage is to clean the ulcer. This can be done by gentle washing in warm tap water. Sometimes saline (salt water) is used instead. The aim of this is to remove debris and dead tissue that accumulates on the surface of the ulcer between dressing changes. Removal of this helps ulcer healing.

If there is a large amount of dead tissue, the nurse may need to remove it using a technique called debridement. Specially designed dressings may be used to pull away dead tissue or chemicals to dissolve the dead tissue. It is performed under local anaesthetic (where the area is numbed), so it does not hurt.

A simple, non-sticky dressing will be used to dress your ulcer. This will aid healing, improve comfort and control any pus. Many patients find they can manage cleaning and dressing of their own ulcer under the supervision of a district nurse.

Treating an infected leg ulcer

Sometimes an ulcer will produce a large amount of pus and become more painful, and some red inflammation may develop around the ulcer. These symptoms may be a sign of infection.

Cleaning of the ulcer should continue as usual and a dressing applied. Where possible, application of compression treatment should also be used. However, sometimes the leg may be too painful to allow this. Temporarily, compression can be reduced or avoided until the leg is more comfortable.
You will be prescribed a seven-day course of antibiotic tablets to treat your infection. In most cases you will be given penicillin. If you are allergic to penicillin, an alternative antibiotic such as erythromycin can be used.

Side effects of antibiotics are usually mild and short-lived. They include:

You will need to return to your nurse daily, or every other day, to ensure your antibiotics are working, until the infection has cleared. If there is no improvement, your nurse may change your antibiotic, which you may need to take for up to two weeks.

In rare cases where the infection gets worse and you begin to feel very unwell, you may need intravenous antibiotic treatment (antibiotics injected into the vein) in hospital.

The aim of antibiotic treatment is to treat the infection – however, antibiotics have no beneficial effect on ulcer healing and should only be used in short courses to treat ulcers that have become infected.

Follow-up treatment

You should return to your nurse once a week to have your dressings and compression bandages changed. They will also monitor the ulcer to see how well it is healing. Once your ulcer is healing well, you may only need to see your nurse once a month.

Treating associated symptoms

Pain

Venous leg ulcers can often be painful. Mild to moderate leg pain can be treated using paracetamol. However, if your pain is more severe and does not respond to paracetamol, your healthcare professional may prescribe a combination of paracetamol and ibuprofen.

If after treatment your leg pain has continued to worsen, you should inform your nurse because you may have developed a complication such as an infection.

Leg swelling (oedema)

Venous leg ulcers are often accompanied by oedema (fluid-filled swelling of your ankles and feet). This is effectively controlled with the use of compression bandages or graduated elastic medical compression stockings.

Keeping your affected leg elevated will also usually help ease any swelling. Try keeping your leg raised above hip level for 30 minutes, three or four times a day. Putting pillows or cushions under your feet when you are asleep may also help.

However, it is important that you also keep as active as possible and aim to continue with your normal activities. Regular exercise, such as a daily walk, will help reduce swelling in the legs but do not stand still for long periods of time.

Itchy skin

Itchy and irritated skin associated with a venous ulcer is known as varicose eczema, and is caused by the fluids leaking out of veins into surrounding tissue.

If you have severe or worsening varicose eczema, your nurse will first need to rule out cellulitis (a bacterial infection of the deep layer of skin). If you have cellulitis, you will be given antibiotics.

To treat varicose eczema, your nurse may suggest using an emollient (moisturiser) on the affected area, as well as a mild corticosteroid cream or ointment. These will ease itching and encourage the skin to heal.

If your eczema does not improve or continues to get worse despite treatment, you may have an allergic reaction known as contact dermatitis. You may be allergic to your dressing, emollient or corticosteroid.

If contact dermatitis is suspected, you may need to be referred to a dermatologist (skin specialist) for a patch test. This involves taping a small amount of the suspected allergen to your skin for 48 hours to see how it reacts.

Contact dermatitis can occur at any stage of your treatment for a venous ulcer, and not just at the start.

Specialist treatment

If your venous leg ulcer does not heal, even after two to three months of treatment, you will need to be referred for specialist treatment to find out why. The specialist will be able to arrange further investigations such as colour duplex ultrasound imaging or biopsy of the ulcer to determine what is preventing your ulcer from healing.

Varicose veins are a common cause of leg ulcers and modern treatments can be used alongside compression treatments to improve and maintain ulcer healing.

In very rare cases, a venous leg ulcer may not heal, even after specialist treatment. If this is the case, your healthcare professional will aim to make your ulcer as easy to live with as possible by controlling any associated symptoms and improving your mobility. You may be offered long-term psychological support if it is needed.

After the leg ulcer has healed

Once a leg has suffered a venous ulcer, there is a one in four chance of further ulceration developing within the next two years. The most effective method of preventing this is to wear a graduated elastic medical compression stocking at all times when you are out of bed. Your nurse will help you find a stocking that fits correctly and which you can manage yourself.

Various accessories are available to help you put these on and take them off.

Treating underlying conditions

Venous ulcers are caused by the failure of valves in the veins of the leg. Commonly, this arises in the surface veins and causes varicose veins.

Read more information about how varicose veins are treated.

Sometimes, it is the deep veins of the leg that are the problem. These may be damaged following a deep vein thrombosis (DVT). Unfortunately, the valves in deep veins are not easily repaired and compression treatment (see above) is the best method in most cases. There are no drugs that can be taken or topical ointments that can be applied to heal the ulcer.

Treatment for venous leg ulcers should always be carried out by a healthcare professional trained in leg ulcer management. In most cases, this will be a trained practice or district nurse.

Read more information about preventing a venous leg ulcer.

Complications

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A venous leg ulcer can result in several complications, including loss of mobility and the risk of infection.

You may find it difficult and painful to move around if you have a venous leg ulcer. This immobility can make the ulcer worse, as blood pressure rises when you are not moving, aggravating your ulcer. Living with a venous leg ulcer can also be difficult. Ulcers can be painful and take a long time to heal, and you may find you need a lot of time off work.

For some people, the loss of independence and social isolation can cause emotional and psychological distress. You may be offered long-term psychological support if it is needed.

Infection

Venous leg ulcers can become infected, so it is important to look out for any signs of infection. These include swelling, redness, pus and increased pain. You may also have a fever and feel generally unwell.

If your venous leg ulcer becomes infected, it can be treated using antibiotics, such as [flucloxacillin].

In rare cases, or if an infection is left untreated, the bacteria could spread and lead to other conditions such as:

  • osteomyelitis – an infection of the nearby bone which causes fever, nausea and severe pain in the affected bone
  • blood poisoning (septicaemia) – if you have blood poisoning, you may develop a fever and headaches, and have vomiting, diarrhoea and rapid breathing

If you have osteomyelitis or blood poisoning, you will need to be admitted to hospital in order to receive treatment with antibiotics, which are usually given intravenously (directly into your vein through a drip).

Malignant change

In a venous ulcer present for many months or years, a malignant tumour may arise. These have many different appearances, but if an ulcer gets worse and extends despite appropriate treatment, this diagnosis should be considered.

Your doctor will refer you to a hospital specialist for a biopsy so that the ulcer can be examined under a microscope. The treatment includes removal of the ulcer, including the malignant area. Sometimes skin grafting is necessary as part of this treatment.

Prevention

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You can help to prevent a venous leg ulcer in several ways, such as wearing a compression stocking, losing weight and taking care of your skin.

People most at risk of developing a venous leg ulcer are those who have previously had an ulcer. Once a leg has suffered a venous ulcer, there is a one in four chance of further ulceration developing within the next two years.

Compression stockings

Venous leg ulceration is almost always preceded by the skin changes of lipodermatosclerosis. Your doctor will help you recognise this problem and refer you to a vascular specialist for further tests and treatment.

In people who have troublesome varicose veins causing skin damage as well as problems following a deep vein thrombosis (DVT), the best method of treatment is to start with graduated elastic medical compression stockings.

Your nurse will help you find a stocking that fits correctly and which you can manage yourself. Various accessories are available to help you put these on and take them off.

Graduated elastic medical compression stockings should also be worn if you have had a previous leg ulcer, to prevent another one forming.

Lose weight

If you are obese, then losing weight can help prevent venous leg ulcers because excess weight contributes to high pressure in the leg veins, which can cause damage to the skin. Venous ulcers are much more common among people who are obese than in people of normal weight.

To lose weight do at least 150 minutes of moderate-intensity exercise every week, eat smaller portions and have only healthy snacks between meals. A gradual weight loss of around 0.5kg (1.1lbs) a week is usually recommended.

A low-fat, high-fibre diet that includes wholegrains and plenty of fresh fruit and vegetables (at least five portions a day) is recommended.

Skin care

Use an emollient (moisturiser) regularly on your legs, particularly if you have had a previous venous leg ulcer. You can use it as often as you like as there are no safety concerns about using it too much. The motion of rubbing the emollient into your skin also helps to boost your circulation.

Examine your legs regularly for broken skin, blisters, swelling and redness. Treating minor skin conditions as and when they occur may help prevent a venous leg ulcer developing.

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