Leg ulcer, venous
Introduction
A leg ulcer is a chronic (long-lasting) non-healing wound on your leg or foot which takes longer than six weeks to heal.
Symptoms of a leg ulcer include pain, itching and swelling in the affected leg.
Types of leg ulcer
The most common type of leg ulcer is a venous leg ulcer, accounting for 80-85% of all cases. Venous leg ulcers occur when persistently high blood pressure in the veins of the legs (venous hypertension) causes damage to the skin.
Other common types of leg ulcer can include:
- arterial leg ulcers, which result from poor blood circulation in the arteries
- diabetic leg ulcers, which can occur as a result of the high blood sugar associated with diabetes
- vasculitic leg ulcers, associated with chronic inflammatory disorders such as rheumatoid arthritis and lupus
- traumatic leg ulcers, caused by injury to the leg
- malignant leg ulcers, arising from a tumour of the skin of the leg
How common are venous leg ulcers?
Venous leg ulcers are uncommon in the general population, affecting an estimated 1 person in 500 in the UK.
Rates of venous leg ulcers rise sharply with age. It is estimated that in people who are over the age of 80, 1 in every 50 are affected by venous leg ulcers. The two biggest risk factors for venous leg ulcers are:
Outlook
The outlook for small ulcers is generally good. With appropriate treatment, 70% of small ulcers will heal within 12 weeks. Larger ulcers may take longer to heal.
Treatment for venous leg ulcers usually involves cleaning and dressing the wound, and applying compression bandages to control the blood pressure inside the legs better.
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, but 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 the healing of the ulcer, so are not part of routine treatment.
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Symptoms
A venous leg ulcer is a chronic non-healing wound with broken skin and exposed tissue. If you have a venous leg ulcer, you may also have:
- swollen ankles that are 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 hyperpigmentation)
- 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 which can cause:
- leg pain, which can be continuous
, or intermittent (it 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 GP 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.
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Causes
A venous leg ulcer develops as a result of 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 healthy leg veins, blood flows towards the heart. These valves prevent blood from flowing backwards. However, if the valves in your veins 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 that are hidden from view. The pressure inside these veins is increased and this can damage the skin.
The constant high blood pressure in your legs causes fluid to leak out of the veins. The fluid causes swelling and damages the skin, which becomes hard and inflamed, leading to an ulcer.
Risk factors
A number of factors increase your risk of developing a venous leg ulcer including:
- being obese, 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 the valves inside the veins
- varicose veins, swollen and enlarged veins caused by malfunctioning valves
- a previous leg injury, such as a broken or fractured bone, which may cause a deep vein thrombosis
- increasing age, generally, the older you get the less efficient your blood circulation system becomes
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Diagnosis
See your GP If you think that 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 GP or nurse will check the size, depth and position of your ulcer. They will ask you whether it has been leaking fluid, whether the ulcer is painful and what that pain is like. They will also try to determine the cause of the ulcer by asking you about any underlying conditions that you may have, such as varicose veins, diabetes, or deep vein thrombosis, and any previous injuries, ulcers or surgery that you may have had on your affected leg.
The physical examination will involve your GP or nurse examining your leg both 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 signs 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 that the arteries in your leg are working properly.
Doppler studies
In order to rule out a condition affecting your arteries (vessels that carry blood from your heart to the rest of your body), your GP or nurse will also do a test known as a Doppler study to check for peripheral arterial disease.
In peripheral arterial disease, the blood flow to the legs is reduced. In mild cases the only symptom may be pain in the calf on walking (intermittent claudication), which comes on after 5-10 minutes. In more severe cases, pain may occur in the feet or toes at night. If the blood flow is very poor, gangrene of the toes may occur or an ulcer may arise in the ankle region.
Signs of peripheral arterial disease include hair loss in the affected area, coldness of the leg and loss of the pulses in the leg. The cause of these problems is reduced blood pressure in the arteries.
Your GP or nurse should perform a Doppler study on both of your legs. 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. Peripheral arterial disease is diagnosed when the blood pressure in the legs is reduced compared to that in the arm.
The importance of checking the arterial system is that 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 GP or nurse is unsure about your diagnosis, or about what has caused your venous 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.
For more information, see the A-Z pages on Peripheral arterial disease
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Treatment
A venous ulcer can be healed by:
- the application of strong sustained compression with a bandage or a stocking, and
- treating the underlying cause of the ulcer
When appropriate, both treatments can be used at the same time.
Venous ulcers are caused by failure of valves in the veins of the leg (see previous sections). Commonly, this arises in the surface veins and causes varicose veins. These can be treated using one of the modern methods mentioned in the section on Varicose veins - treatment.
Sometimes, it is the deep veins of the leg that are the problem. These may be damaged following a deep vein thrombosis. Unfortunately, the valves in deep veins are not easily repaired and compression treatment 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. You may need to be referred to a trained practice, or distrcit nurse.
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 that 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 can be applied after removing both stockings. Many patients find that they can manage this themselves.
There are many different types of bandage that can be 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 a period of one to seven days, depending on how often ulcer dressing changes are required.
Dressing the ulcer
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 your ulcer with warm tap water, or saline (salt water solution). 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. If this is the case, you will have a local anaesthetic (where the area is numbed), to reduce any pain.
A simple, non-sticky dressing will be used to dress your ulcer, which will aid healing, improve comfort, and control any pus. Many patients find that they can manage cleaning and dressing of their own ulcer under the supervision of a district nurse.
Treatment for 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 will continue as usual and a dressing will be applied. Where possible, application of compression treatment will also be used. However, sometimes, your healthcare professional will not apply a compression bandage at this stage because doing so would be too painful. 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:
- nausea
- vomiting
- abdominal pain
- diarrhoea
You will need to return to your nurse daily, or every other day to ensure that 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 worsens 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 will need to return to your nurse to have your dressings and compression bandages changed once a week. Once your ulcer is healing well, you may only need to return to 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 codeine phosphate.
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 very effectively controlled with the use of compression bandages or graduated elastic medical compression stockings.
Keeping your affected leg elevated will also usually help to 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.
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 your veins into the 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 a course of 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 the itching and encourage your skin to heal.
If, despite treatment, your varicose eczema does not improve or continues to get worse, it may be due to an allergic reaction, known as contact dermatitis. You may be allergic to your dressing, emollient or corticosteroid.
If you have contact dermatitis, you may need to be referred to a dermatologist (skin-care specialist) for a patch test. This involves a small amount of the suspected allergen being taped to your skin for 48 hours to see how it reacts.
Contact dermatitis can occur at any stage of your treatment for venous ulcer, and not just at the start of your treatment.
Specialist treatment
If your venous leg ulcer does not heal, even after 2-3 months of treatment, you will need to be referred for specialist treatment to find out why it has not healed. The specialist may be able to arrange further investigations such as colour duplex ultrasound imaging or biopsy of the ulcer to the things that are preventing your ulcer from healing.
Varicose veins are a common cause of leg ulcers and modern methods of management of these 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 also have access to long-term psychological support if it is needed.
After your 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.
Varicose veins is a common cause of venous leg ulcers. These can be managed by modern methods of treatment. The risk of a further leg ulcer developing is greatly reduced if varicose veins causing an ulcer are treated. You should discuss referral to a vascular specialist for assessment for this treatment as part of the management of your leg ulcer.
Self-care advice
The following advice may help your venous leg ulcer to heal more quickly.
- Try to keep active by walking regularly. Immobility can worsen venous leg ulcers and the associated symptoms, such as oedema (swollen, fluid-filled areas).
- Whenever you are sitting or lying down, try and 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.
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Complications
A venous leg ulcer can result in several complications, which are detailed below.
Immobility
You may find it difficult and painful to move around if you have a venous leg ulcer. This can make the ulcer worse, as blood pressure rises when you are immobile, aggravating your ulcer.
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.
Loss of quality of life and general functioning
Living with a venous leg ulcer can be difficult. Ulcers can be painful and take a long time to heal, and you may find that you need a lot of time off work. For some people, the loss of independence and social isolation can cause emotional and psychological distress.
Osteomyelitis
The bacteria from an infected venous leg ulcer can spread and cause osteomyelitis. This is an infection of the nearby bone. Osteomyelitis causes fever, nausea and severe pain in the affected bone. If you have osteomyelitis, you will need to be admitted to hospital in order to receive treatment with antbiotics, which are usually given intravenously (through a drip directly into your vein).
Blood poisoning (septicaemia)
If a venous leg ulcer becomes infected, the bacteria can spread to your blood stream and multiply rapidly, causing blood poisoning, or septicaemia. If you have blood poisoning, you may develop a fever and headaches, and have vomiting, diarrhoea and rapid breathing. Blood poisoning can be treated using antibiotics, you will need to be admitted to hospital to receive treatment.
Malignant change
In a venous ulcer that has been 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.
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Prevention
Compression stockings
Venous leg ulceration is almost always preceded by the skin changes of lipodermatosclerosis. Your GP will help you recognise this problem and advise on referral 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, the best method of treatment is to start with graduated elastic medical compression stockings.
Graduated elastic medical compression stockings should also be worn if you have had a previous leg ulcer, to prevent another one forming (see below)
Lose weight
If you are obese then losing weight can help to prevent venous leg ulcers because excess weight contributes to high blood 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 30 minutes of daily exercise, 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. For more advice, see the section on Healthy Eating.
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 it is impossible to use too much. The motion of rubbing the emollient into your skin helps to boost your circulation.
Examine your legs regularly for broken skin, blisters, swelling and redness. Treating minor skin ailments as and when they occur may help to prevent a venous leg ulcer developing.
If you have had a previous leg ulcer...
People who are 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. 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.
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