Venous leg ulcer
A leg ulcer is a long-lasting (chronic) sore on your leg or foot that takes more than four to six weeks to heal. They most often develop on the inside of the leg, just above the ankle.
The symptoms of a venous leg ulcer include pain, itching and swelling in the affected leg. There may also be discoloured or hardened skin around the ulcer, and the sore may produce a foul-smelling discharge.
See your GP if you think you have a leg ulcer, as it will not heal on its own. Your GP will examine your leg and may carry out additional tests to rule out other conditions.
What causes venous leg ulcers?
A venous leg ulcer is the most common type of leg ulcer, accounting for over 90% of all cases.
Venous leg ulcers can develop after a minor injury, where persistently high pressure in the veins of the legs has damaged the skin.
Who is affected
Venous leg ulcers are estimated to affect around 1 in 500 people in the UK, although they become much more common with age. It's estimated that around 1 in 50 people over the age of 80 has one.
You are more at risk of developing one if you find it difficult to move around because of a problem such as osteoarthritis, a leg fracture, obesity or paralysis. You are also more at risk if you have recently had an operation on your leg, such as a hip replacement or knee replacement.
People with varicose veins (swollen and enlarged veins) also have a higher risk of developing venous leg ulcers.
How venous leg ulcers are treated
Most venous leg ulcers will heal within three to four months if they are treated by a healthcare professional trained in compression therapy for leg ulcers. However, some ulcers may take longer to heal, and a very small number never heal.
Treatment usually involves cleaning and dressing the wound and using compression bandages to improve the flow of blood in the legs. Antibiotics may also be used if the ulcer becomes infected, but they do not help uninfected ulcers heal.
However, unless the underlying cause of the ulcer is addressed, there is a high risk of a venous leg ulcer recurring after treatment. Underlying causes could include immobility, obesity or varicose veins.
Can venous leg ulcers be prevented?
There are several ways to help prevent a venous leg ulcer, such as the long-term use of compression stockings, losing weight if you are obese, exercising regularly and elevating your leg when possible.
This is particularly important if you have previously had a leg ulcer – once a leg has suffered a venous ulcer, there is a significant chance of further ulcers developing within a few months or years.
Venous leg ulcers most often develop on the inside of the leg, just above the ankle
Other types of leg ulcer
Other common types of leg ulcer include:
arterial leg ulcers – caused by poor blood circulation in the arteries
diabetic leg ulcers – caused by 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 – caused by a tumour of the skin of the leg
Symptoms of a venous leg ulcer
Venous leg ulcers are open, often painful, sores in the skin that take more than four to six weeks to heal. They most often develop on the inside of the leg, just above the ankle.
If you have a venous leg ulcer, you may also have:
swollen ankles (oedema)
discolouration and darkening of the skin around the ulcer
hardened skin around the ulcer, which may make your leg feel hard and resemble the shape of an upside-down champagne bottle
a heavy feeling in your legs
aching or swelling in your legs
red, flaky, scaly and itchy skin on your legs (varicose eczema)
swollen and enlarged veins on your legs (varicose veins)
an unpleasant and foul-smelling discharge from the ulcer
Signs of an infection
A venous leg ulcer can be susceptible to bacterial infection. Symptoms of an infected leg ulcer can include:
a green or unpleasant discharge coming from the ulcer
redness and swelling of the skin around the ulcer
a high temperature (fever)
When to seek medical advice
You should contact your GP if you think you have developed a venous leg ulcer. They are unlikely to get better on their own, as they usually require specialist medical treatment.
You should also contact your GP or leg ulcer specialist if you have been diagnosed with a venous leg ulcer and have symptoms that suggest it could be infected.
Causes of venous leg ulcers
A venous leg ulcer can develop after a minor injury if there is a problem with the circulation of blood in your leg veins. If this happens, the pressure inside the veins increases.
This constant high pressure can gradually damage the tiny blood vessels in your skin and make it fragile. As a result, your skin can easily break and form an ulcer after a knock or scratch.
Unless you have treatment to improve the circulation in your legs, the ulcer can take a long time to heal.
Who's most at risk?
A number of factors can increase your risk of developing a venous leg ulcer, including:
obesity – this increases the risk of high pressure in the leg veins
not being able to move for a long period of time – this can weaken the calf muscles, which can affect circulation in the leg veins
having previously had deep vein thrombosis (DVT)– blood clots that develop in the leg, which can damage valves
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 DVT
previous surgery to the leg, such as a hip replacement or knee replacement, which can prevent you from moving about
increasing age – as people generally find it harder to move about as they get older
Diagnosing a venous leg ulcer
If you think you may have a venous leg ulcer you should see your GP, as the condition is unlikely to improve without specialist treatment.
A diagnosis is largely based on your symptoms and a physical examination of your affected leg, although additional tests may be required.
Physical examination and medical history
Your GP or practice nurse may examine your leg, both when you are standing up and lying down. Varicose veins will be more obvious when you are standing up, and it will be easier to look at the ulcer when you are lying down.
They will ask whether you have any additional symptoms associated with venous leg ulcers, such as swelling in your ankles and discoloured or hardened skin. They will also feel your pulse at your ankles to make sure the arteries in your leg are working properly.
Your GP or nurse may try to determine the cause of the ulcer by asking 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.
To rule out peripheral arterial disease (a condition affecting the arteries) as a possible cause of your symptoms, your GP or nurse will carry out a test known as a Doppler study.
The test involves measuring the blood pressure in your ankles and comparing it to the blood pressure in your upper arms. These measurements are taken with a Doppler probe, which uses sound waves to determine the flow of blood in your arteries.
The arterial blood pressure should be about the same in your arms and legs. However, if you have peripheral arterial disease, the blood pressure in your ankles will be lower than that in your arms.
It is important to carry out this check before a diagnosis is made because the treatment for peripheral arterial disease is different to that for venous leg ulcers. One of the main treatments used for venous ulcers is wearing compression bandages to improve the circulation in your legs, but this can make things worse if you have peripheral arterial disease.
Referral to a specialist
In some cases, your GP or nurse may decide to refer you to a specialist in conditions affecting the blood vessels (vascular specialist) for further examination and treatment.
For example, you may be referred to a vascular specialist if your GP or nurse is unsure about your diagnosis, or if they suspect your ulcer may be the result of certain underlying conditions, such as diabetes or rheumatoid arthritis.
If you are referred to a specialist, you may have a further test called a duplex ultrasound scan to check the health of the blood vessels in your legs in detail. This entirely pain-free scan uses sound waves to build up a picture of the blood vessels in your legs, then assesses the flow of blood through them.
Treating a venous leg ulcer
With appropriate treatment, most venous leg ulcers will heal within three to four months.
Treatment should always be carried out by a healthcare professional trained in compression therapy for leg ulcers. Usually, this will be a practice or district nurse.
Cleaning and dressing the ulcer
The first step is to remove any debris or dead tissue from the ulcer and apply an appropriate dressing. This will provide the best conditions for the ulcer to heal.
A simple, non-sticky dressing will be used to dress your ulcer. This will usually need to be changed once a week. Many people find they can manage cleaning and dressing their own ulcer under the supervision of a nurse.
To help improve the circulation in your legs, your nurse will need to apply a firm compression bandage over the affected leg. These bandages are designed to squeeze your legs and encourage blood to flow upwards, towards your heart.
There are many different types of bandage used to treat venous leg ulcers, which can be made up of two, three or four different layers. The application of a compression bandage is a skilled procedure and should only be done by a healthcare professional trained in leg ulcer management.
Bandaging of the leg is usually done after the ulcer has been dressed. The bandage is changed once a week, when the dressing is changed.
When compression bandages are first applied to an unhealthy ulcer, it usually becomes more painful. Ideally, you should have paracetamol or an alternative painkiller prescribed by your GP. The pain will lessen once the ulcer starts to heal, but this can take up to 10-12 days.
It’s important to wear your compression bandage exactly as instructed by your nurse. If you have any problems, it's usually best to contact your nurse, instead of trying to remove it yourself. If the compression bandage feels a little too tight and is uncomfortable in bed at night, getting up for a short walk will usually help.
However, if you get severe pain at the front of your ankle or on the top of your foot, or if your toes become blue and swollen, you will need to cut the bandage off. Once you remove the bandage, make sure you keep your leg highly elevated and contact your nurse as soon as possible.
Treating associated symptoms
Swelling in the legs and ankles
Venous leg ulcers are often accompanied by swelling of your feet and ankles (oedema), which is caused by fluid build-up. This can be controlled by compression bandages.
Keeping your affected leg elevated whenever possible, ideally with your toes at the same level as your eyes, will also help ease swelling. You may find it helpful to put something firm – such as a rigid suitcase – under the end of your mattress, to help keep your legs raised while you sleep.
You should also keep as active as possible and aim to continue with your normal activities. Regular exercise, such as a daily walk, will help reduce leg swelling. However, you should avoid sitting without your legs raised or standing still for longer than an hour at a time.
Some people with venous leg ulcers develop rashes with scaly and itchy skin.
This is sometimes caused by a condition called varicose eczema, which can be treated with a moisturiser (emollient) and occasionally a mild corticosteroid cream or ointment. In severe cases, you may need to be referred to a dermatologist (skin specialist) for treatment.
Itchy skin can also sometimes be caused by an allergic reaction to the dressings or creams applied by your nurse. If this happens, you may need to be tested for allergies.
It’s important to avoid scratching your legs if they feel itchy, because this could damage the skin and lead to further ulcers.
Looking after yourself during treatment
To help your ulcer heal more quickly, follow the advice below:
Try to keep active by walking regularly. Sitting and standing still without elevating your legs can make venous leg ulcers and swelling worse.
Whenever you are sitting or lying down, try to keep your affected leg elevated.
Regularly exercise your legs by moving your feet up and down, and rotating them at the ankles. This can help encourage better circulation.
Stop smoking, eat a healthy diet and moderate your alcohol consumption. This can help the ulcer heal faster.
Be careful not to injure your affected leg, and wear comfortable, well-fitting footwear.
You may also find it helpful to attend a local healthy leg club, such as those provided by the Lindsay Leg Club Foundation, for support and advice about living with a leg ulcer.
Treating an infected ulcer
An ulcer will sometimes produce a large amount of pus and become more painful. There may also be some redness around the ulcer. These symptoms may be a sign of infection.
If your ulcer becomes infected, it should be cleaned and dressed as usual, although you may need to stop wearing your compression bandage until the infection has cleared.
You should also keep your leg elevated whenever possible, and you will be prescribed a seven-day course of antibiotics.
The aim of antibiotic treatment is to heal the infection. However, they have no beneficial effect on ulcer healing and should only be used in short courses, in order to treat ulcers that have become infected.
You should visit 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 will probably need to see your nurse less often.
After the ulcer has healed
Once you have had a venous leg ulcer, there is a significant chance another ulcer could develop within the next few months or years.
The most effective method of preventing this is to wear compression stockings at all times when you are out of bed. Your nurse will help you find a stocking that fits correctly and that you can manage yourself.
Various accessories are available to help you put them on and take them off.
Preventing a venous leg ulcer
You can help reduce your risk of developing 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 a leg ulcer. Studies have shown there is a significant chance another could develop a few months or years after a previous ulcer heals.
If you have previously had a venous leg ulcer, or your GP thinks you may be at risk of developing one (for example, if they notice hardening of the skin on your legs, which often occurs after an ulcer), treatment with compression stockings may be recommended.
These stockings are specially designed to steadily squeeze your legs, which improves your circulation. They are usually tightest at the ankle and get gradually looser as they go further up your leg – this encourages blood to flow upwards, towards your heart.
To be most effective, these stockings need to be worn at all times when you are out of bed.
Compression stockings are available in a variety of different sizes, colours, styles and pressures. A nurse can help you find a stocking that fits correctly and that you can manage yourself. There are various accessories you can buy to help get the stockings on and off.
If you are obese, losing weight can help prevent venous leg ulcers. This is because excess weight leads to high pressure in the veins in your legs, which can damage your skin. Venous ulcers are much more common among people who are obese than in people of normal weight.
To help you lose weight, at least 150 minutes of moderate-intensity exercise every week is recommended. You should also try to have a healthy, balanced diet.
If you are unable to do 150 minutes of exercise a week, you should aim for 45 minutes of moderate intensity exercise at least three times a week. Walking is a great form of moderate intensity exercise, and you should avoid sitting or standing for long periods. Elevating your legs whenever possible can also help.
Treating underlying problems
In some cases, you may be able to receive treatment for a condition that can increase your chances of developing a venous leg ulcer, such as varicose veins.
Varicose veins can often be treated using a procedure where a catheter (a thin, flexible tube) is inserted into the affected veins, and high-frequency radio waves or lasers are used to seal them.
Alternatively, you may need surgery to repair the damage to your leg veins, or to remove the affected veins altogether.