Venous Leg Ulcers

When poor venous circulation leads to a non-healing wound

What is a venous leg ulcer?

A venous leg ulcer is a wound or break in the skin of the lower leg that has difficulty healing because of problems with the veins.

They most commonly occur between the knee and ankle, particularly around the inside of the lower leg and ankle.

Venous ulcers usually develop because pressure within the leg veins remains too high over a long period of time. This can damage the skin and surrounding tissues and make normal healing difficult.

NICE defines a venous leg ulcer for referral purposes as a break in the skin below the knee that has not healed within 2 weeks.

Why do venous leg ulcers develop?

The veins in the legs contain valves that help blood travel back towards the heart.

When these valves become damaged or ineffective, blood can flow backwards and collect in the lower leg. This causes chronic venous hypertension.

Over time, the increased pressure can cause:

  • Persistent ankle swelling

  • Varicose veins

  • Brown pigmentation

  • Venous eczema

  • Thickening or hardening of the skin

  • Fragile skin

  • Poor healing following even a minor injury

Eventually, a small break in the skin can develop into an ulcer.

Who is more at risk?

Venous leg ulcers are more likely in people with:

  • Chronic venous insufficiency

  • Varicose veins

  • Previous deep vein thrombosis (DVT)

  • Previous leg ulcers

  • Persistent lower-leg swelling

  • Reduced mobility

  • Increasing age

  • Obesity

  • Previous injury or surgery to the leg

A previous DVT can be particularly important because it may permanently damage the valves within the deep veins.

What does a venous leg ulcer look like?

Venous ulcers commonly occur in the gaiter area of the lower leg, particularly around the medial ankle.

They may be:

  • Shallow rather than deeply punched out

  • Irregular in shape

  • Moist or exuding fluid

  • Surrounded by swollen or discoloured skin

The surrounding leg may also show signs of chronic venous disease such as:

  • Brown or rusty pigmentation

  • Venous eczema

  • Oedema

  • Varicose veins

  • Hardened skin

  • Ankle flare

However, appearance alone cannot safely determine the cause of a leg ulcer.

Not every leg ulcer is venous

This is very important.

Ulcers can also result from:

  • Peripheral arterial disease

  • Diabetes

  • Neuropathy

  • Pressure

  • Trauma

  • Vasculitis

  • Infection

  • Certain inflammatory conditions

  • More rarely, skin cancer or other underlying disease

Some people have a combination of arterial and venous disease, known as a mixed-aetiology ulcer.

For this reason, a new lower-leg ulcer should be properly assessed rather than simply dressed repeatedly without establishing its cause.

How is a venous leg ulcer assessed?

Assessment usually includes:

  • Your medical history

  • How and when the wound developed

  • Examination of the ulcer

  • Examination of the surrounding skin

  • Swelling and venous changes

  • Foot pulses

  • Assessment of arterial circulation

An Ankle Brachial Pressure Index (ABPI) or equivalent vascular assessment is commonly used to assess the arterial supply before compression treatment is commenced.

Why is an ABPI important?

Compression is the mainstay of treatment for many venous leg ulcers.

However, compression reduces the diameter of the leg and applies pressure to the tissues.

If someone also has significant arterial disease, inappropriate compression could further compromise blood flow into the foot.

The ABPI compares blood pressure at the ankle with blood pressure at the arm and helps identify whether arterial circulation needs further investigation before compression is used.

This is why strong compression should not simply be applied to an undiagnosed leg ulcer.

How are venous leg ulcers treated?

Treatment aims to:

  1. Heal the wound.

  2. Reduce swelling and venous pressure.

  3. Improve blood return up the leg.

  4. Treat the underlying venous problem where possible.

  5. Reduce the chance of the ulcer returning.

With appropriate treatment, many venous leg ulcers heal within several months; the NHS notes that they often heal within around 6 months.

Wound care

The wound may need:

  • Cleaning

  • Removal of dead or unhealthy tissue where appropriate

  • An appropriate wound dressing

  • Regular review

Dressings provide a suitable environment for healing, but the dressing alone does not correct the underlying venous pressure.

That is why compression is usually such an important part of treatment.

Compression therapy

Where arterial circulation is satisfactory, compression helps counteract the high pressure within the veins.

Compression may be provided using:

  • Compression bandaging

  • Compression hosiery

  • Adjustable compression wraps

  • Other specialist compression systems

The exact system depends on the wound, swelling, vascular assessment and individual circumstances.

Compression treatment for a venous ulcer should be provided by a healthcare professional appropriately trained in its use.

Why does walking help?

Walking activates the calf muscle pump.

Each time the calf muscles contract, they squeeze the deep veins and help propel blood upwards towards the heart.

Where medically appropriate, people with venous ulcers are therefore usually encouraged to remain active rather than avoiding movement altogether.

Elevation of the leg when resting can also help reduce swelling.

Does an ulcer automatically need antibiotics?

No.

This is a particularly important misconception.

Most leg ulcers contain bacteria on their surface, but this does not automatically mean they are clinically infected.

NICE advises that antibiotics do not improve healing in a leg ulcer that has no clinical signs of infection.

Antibiotics are generally required when there are signs such as:

  • Redness or swelling spreading beyond the ulcer

  • Increasing warmth

  • Increasing pain

  • Fever or systemic illness

So an ulcer looking moist, having bacteria present on a swab or producing some discharge does not automatically mean antibiotics are required.

Signs of infection

Seek medical advice promptly if you notice:

  • Increasing pain

  • Rapidly increasing redness or swelling

  • Increasing heat around the wound

  • Increasing or changing discharge

  • Fever

  • Chills or shivering

  • Feeling generally unwell

An infected leg ulcer should be reassessed if symptoms worsen rapidly or do not begin to improve within 2–3 days of starting antibiotic treatment.

When is infection an emergency?

Hospital assessment may be required if an infected ulcer is associated with serious illness such as:

  • Sepsis

  • Suspected infection of the bone

  • Rapidly spreading infection

  • Severe pain that seems disproportionate to the appearance of the wound

When should a leg ulcer be referred?

NICE recommends referral to a vascular service for:

  • A venous leg ulcer that has not healed within 2 weeks

  • A healed venous leg ulcer

The reason for referring someone whose ulcer has already healed is that treating underlying venous disease may help reduce the likelihood of recurrence.

Why treat the veins if the wound has healed?

Because the wound is often the result of the venous problem rather than the problem itself.

If significant venous reflux remains untreated, the increased pressure continues and another ulcer may develop.

A vascular specialist may therefore use duplex ultrasound to identify faulty veins and consider treatments such as:

  • Endothermal ablation

  • Ultrasound-guided foam sclerotherapy

  • Surgery in selected cases

Can venous leg ulcers come back?

Unfortunately, yes.

Recurrence is common if the underlying venous pressure is not controlled.

After healing, ongoing management may therefore include:

  • Compression hosiery where appropriate

  • Regular walking and exercise

  • Weight management

  • Elevating swollen legs

  • Good skin care

  • Treatment of significant venous disease

  • Regular monitoring for early skin breakdown

Looking after the skin

Skin surrounding a venous ulcer can become extremely vulnerable.

Helpful measures may include:

  • Regularly moisturising dry skin

  • Avoiding scratching

  • Treating venous eczema appropriately

  • Protecting the legs from knocks and trauma

  • Wearing suitable footwear

  • Checking the lower legs and feet regularly

If you notice a new area of broken skin, seek advice early rather than waiting for it to become a large wound.

Venous leg ulcers and your podiatry care

At Blackfords Footcare, assessment of the feet and lower limbs may identify changes associated with chronic venous disease, including:

  • Oedema

  • Varicose veins

  • Haemosiderin pigmentation

  • Venous eczema

  • Lipodermatosclerosis

  • Fragile skin

  • Current or previously healed ulceration

Where clinically appropriate, we can also assess the arterial circulation of the lower limb, including Doppler assessment and ABPI.

This is particularly important because a leg wound should not automatically be assumed to be venous, and the safety of compression depends partly upon adequate arterial blood supply.

A venous leg ulcer normally requires coordinated wound, compression and vascular care, rather than routine podiatry treatment alone. Where an ulcer is identified, we can help recognise the problem and recommend appropriate onward care.

Please seek assessment for any break in the skin below the knee that is not healing normally.

A wound that has remained open for 2 weeks meets NICE referral criteria for vascular assessment when venous ulceration is suspected.