Leg Ulcers

A leg ulcer is defined as ‘the loss of skin below the knee on the leg/foot, which takes more than 6 weeks to heal’

Venous leg ulceration is due to sustained venous hypertension, resulting from chronic venous insufficiency and/or impaired calf muscle pump.

Venous Ulcer


  • Common, chronic, recurring
    • Account for 85% of leg ulcers; around 1-3/1000; incidence rises with age (rare below 45)


  • Usually a result of venous insufficiency caused by venous valve dysfunction in the lower limbs, particularly of perforating veins.
  • When the leg muscle contracts, instead of the blood being pushed towards the heart, it can get pushed backward and out of the vein if pressure is great enough.
  • This causes oedema, venous eczema and ulceration

Aetiology/Risk Factors

  • Modifiable
    • Obesity
    • Immobility
    • Smoking
  • Unmodifiable
    • Immobility
    • Personal/family history of varicose veins or venous insufficiency
    • Age
    • DVT history
    • Hx of trauma


  • Usually large, shallow, painless and situated around the medial or lateral malleoli or in the ‘gaiter’ region of the leg
    • May be associated with varicose veins (examine lying and standing), venous eczema, haemosiderin pigmentation, atrophie blanche (smooth, white plaques stippled with telangiectasia) and venous flare
    • Look for other signs of venous insufficiency e.g. oedema; lipodermatosclerosis (rigid, woody hard fibrosis of the skin/subcut tissues causing the leg to resemble an ‘inverted champagne bottle’)
  • Exclude arterial disease
    • Hair loss, cold, pulseless, pale, poor cap refill (NB arterial ulcers are often painful and deeper)
  • Also consider neuropathic ulcers as part of the DDx (painless, deep, usually found on the heel/MTP head/big toe)


  • Doppler studies and ABPI to exclude arterial insuffiency (ABPI <0.8)
  • Swabs
  • Other investigations may be appropriate e.g. FBC (anaemia; leucocytosis); glucose; autoantibodies (vasculitic ulcer) etc

When to refer

  • Suspected malignant ulcer; peripheral arterial disease; diabetes; rheumotoid ulcer/vasculitic ulcer; atypical distribution; suspected contact dermatitis (either as a primary cause or secondary to treatment); non-healing ulcer


  • Uncomplicated (non infected; non persistent)
    • Wash (irrigate and remove slough, necrotic tissue, excess granulation/fibrous tissue) with warm tap water, saline or potassium permanganate solution (latter if malodourous)
    • Dress the wound with a low-adherent dressing (specialist dressings e.g. hydrogels/alginates may be useful for excess slough or exudate (respectively))
    • Compression bandaging
      • 4/3-layer if immobile and 2-layer if mobile
      • NB Contraindicated if ABPI <0.8
      • Change once a week
    • Foot elevation (do NOT prescribe diuretics for oedema)
    • Assess for symptom persistence, development of cellulitis or worsening eczema
    • Pentoxyphilline can be considered to improve healing (specialist use)
  • If the ulcer appears infected, consider swabbing
    • Only prescribe antibiotics if the culture is positive
  • If the surrounding ‘norma’ skin becomes infected (hot, red, painful), consider flucloxacillin or referral for IV antibiotics
  • After the ulcer has healed, the use of compression stockings is recommended to prevent recurrence
  • If there is no improvement after 3 months, consider referral for further investigation and management


  • Immobility
  • Infection
  • Negative impact on QoL and daily function e.g. social isolation, loss of independence etc
  • Osteomyelitis
  • Septicaemia

Arterial Ulcers

Aetiology/Risk factors

  • Coronary heart disease; stroke/TIA; peripheral vascular disease
  • Diabetes mellitus
  • Obesity/immobility
  • Hypertension
  • Smoking
  • Age


  • Often more distal e.g. dorsum of the foot or toes (compared with venous ulcers); usually painful, particularly with leg elevation (e.g. nocturnal)
    • Classic ‘punched out’ appearance with clear edges
    • The base of the ulcer is classically blue/gray (granulation tissue)
    • Commonly associated with features of peripheral arterial disease e.g. hairless, cold, pale, pulseless
  • May have features of other arterial disease e.g. hypertension


  • ABPI (usually <0.8) and Doppler studies
  • Angiography


  • Similar to peripheral arterial disease– may require surgery
  • Concentrate of lowering cardiovascular risk i.e. smoking cessation; weight loss; lipid control;

Neuropathic Ulcers (usually diabetic)

  • Often appear as painless, deep ulcers in the ball of the foot or heel as a result of repeated trauma to the foot

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: