Venous Leg Ulcer

Chronic ulcer of the lower leg (between the knee and the ankle, usually the medial malleolar region) lasting more than 4 to 6 weeks, caused by sustained venous hypertension from valve reflux, outflow obstruction or failure of the calf muscle pump. Accounts for about 70 to 80% of leg ulcers.

• Prevalence is about 0.5 to 1% of adults and up to 4% over 65 years. Most ulcers heal in 12 to 24 weeks with correct treatment, but about 30% persist beyond 6 months and recurrence is 50 to 70% within 3 months if compression is not continued.
• Risk factors: previous deep vein thrombosis, varicose veins, obesity, older age, reduced mobility, ankle stiffness, leg injury or surgery, and family history.
• Mechanism: raised ambulatory venous pressure leads to capillary leak of fibrinogen and red cells, inflammatory cells trapped in the tissue, haemosiderin deposition, fibrosis (lipodermatosclerosis), and breakdown after minor trauma.
• Many patients have a mixed disease with coexisting arterial insufficiency in about 10 to 20%, which changes treatment.

• Shallow, irregular ulcer, with a sloping margin and a granulating or sloughy base, on the medial or lateral gaiter area (lower third of the leg). Exudate is moderate to heavy.
• Surrounding skin: oedema, brown haemosiderin pigmentation, stasis dermatitis, varicose veins, ankle flare, atrophie blanche, and lipodermatosclerosis (hard, woody, tapered "inverted champagne bottle" leg).
• Pain is usually mild and aching, and relieved by elevation. Increasing pain suggests infection, arterial disease, or an alternative diagnosis.
• Infection signs: spreading erythema, warmth, increased pain, purulent or malodorous exudate, friable granulation tissue, and fever.
• Red flags for another cause: ulcer on the foot or toes, punched out ulcer with absent pulses (arterial), diabetic neuropathy, rapidly enlarging painful ulcer with a violaceous border (pyoderma gangrenosum), non-healing ulcer with a raised rolled edge (squamous cell carcinoma, Marjolin ulcer), history of sickle cell disease, vasculitis (palpable purpura), and an atypical distribution.
• Differential diagnosis: arterial ulcer, neuropathic ulcer, vasculitic ulcer, pyoderma gangrenosum, malignant ulcer (squamous cell carcinoma, basal cell carcinoma, melanoma, lymphoma), sickle cell ulcer, calciphylaxis, infective ulcer (tuberculosis, leishmaniasis, Buruli ulcer, ecthyma), pressure ulcer, and drug induced ulcer (hydroxyurea).
• Complications: infection, cellulitis, osteomyelitis, contact dermatitis from dressings, chronic pain, restricted mobility, depression, malignant change, and recurrent ulceration.

• Clinical assessment of the whole limb and patient: history of deep vein thrombosis, varicose surgery, arterial disease, diabetes, rheumatoid disease, trauma, and drugs. Measure the ulcer (length, width, depth, area, tracings or photographs), describe the wound bed, exudate, and edges.
• Measure ankle brachial pressure index with a hand held Doppler before compression: 0.8 to 1.3 is suitable for full compression, 0.5 to 0.8 needs reduced compression under specialist guidance, below 0.5 or above 1.3 (calcified vessels) needs vascular review and toe pressures.
• Venous duplex ultrasound of the superficial, deep and perforating veins with the patient standing: reflux more than 0.5 seconds (superficial and perforating) or more than 1 second (deep) is abnormal. Look for iliac vein obstruction when the history suggests it.
• Swab only clinically infected wounds. Blood cultures if febrile. Bone imaging if probing reaches bone.
• Blood tests: full blood count, glucose or HbA1c, urea and creatinine, albumin, ferritin, CRP, and where relevant sickle screen, vasculitis screen, thrombophilia (only in young or atypical patients).
• Biopsy (4 to 6 mm punch at the edge) for ulcers not healing after 12 weeks of correct treatment, or with atypical features. Avoid biopsy for suspected pyoderma gangrenosum unless necessary (pathergy).
• Patch testing if dermatitis worsens, to exclude contact allergy to dressings and creams.

• Compression therapy, the cornerstone and the single intervention that improves healing:
  • Multicomponent bandaging (a 2, 3 or 4 layer system) or short stretch bandages giving about 35 to 40 mmHg at the ankle, with graduated reduction to about 17 mmHg at the knee, applied from the base of the toes to below the knee. Change once or twice weekly, depending on exudate.
  • Once healed, or for lighter disease, class 2 or 3 graduated compression stockings (23 to 32 mmHg or 34 to 46 mmHg) to be worn indefinitely to prevent recurrence, replaced every 3 to 6 months.
  • Compression is contraindicated when the ankle brachial index is below 0.5, in acute infection with cellulitis that needs to be treated first (modify, do not stop for superficial infection), in uncontrolled heart failure, and in severe peripheral neuropathy without close monitoring.
  • Intermittent pneumatic compression is an alternative for patients who cannot use bandages.
• Wound care:
  • Cleanse with saline or tap water. Debride slough with autolytic (hydrogel, hydrocolloid), mechanical (monofilament pad), enzymatic, or sharp methods, to expose a healthy bed.
  • Dressings that manage exudate and maintain a moist environment: alginates or hydrofibre for heavy exudate, foam for moderate exudate, hydrocolloid or low adherent pads for light exudate. Avoid topical antibiotics, perfumed products, lanolin and other sensitisers.
  • Protect the periwound skin with zinc oxide paste or a barrier film, and treat stasis dermatitis with a potent steroid ointment for 1 to 2 weeks.
• Leg elevation: raise the leg so the feet are at or higher than the level of the heart for 30 minutes, 3 to 4 times daily, and at night when possible, and encourage ankle exercises and walking to activate the calf muscle pump.
• Infection (only when clinically infected, not for colonisation):
  • Cellulitis: flucloxacillin 500 mg to 1 g orally 6 hourly for 7 to 14 days, or clarithromycin 500 mg 12 hourly, or doxycycline 100 mg 12 hourly in penicillin allergy. Severe infection: flucloxacillin 2 g IV 6 hourly or cefazolin 2 g IV 8 hourly, with vancomycin 15 to 20 mg/kg IV 8 to 12 hourly (adjusted to levels) if MRSA risk.
  • Pseudomonas or mixed infection: ciprofloxacin 500 mg orally 12 hourly, or piperacillin tazobactam 4.5 g IV 6 hourly.
  • Topical antiseptics such as cadexomer iodine, polyhexanide, or silver dressings can be used for 2 weeks for local critical colonisation.
  • Osteomyelitis requires bone sampling and 6 weeks of therapy.
• Adjunctive drug therapy to speed healing in ulcers that heal slowly:
  • Pentoxifylline 400 mg orally 8 hourly, with compression, for 6 months (reduce to 400 mg 12 hourly if creatinine clearance is below 30 mL/min). Avoid in recent haemorrhage, and watch for gastrointestinal upset.
  • Micronised purified flavonoid fraction 500 mg orally 12 hourly, for 6 months.
  • Aspirin 300 mg daily has limited evidence for healing. Use it only if there is a separate indication.
  • Oral zinc is of value only in documented deficiency.
• Treat the venous disease (reduces recurrence in patients with superficial reflux):
  • Endovenous thermal ablation (laser or radiofrequency) or ultrasound guided foam sclerotherapy (polidocanol 1 to 3% foam, up to 10 mL per session) of the incompetent great or small saphenous vein and tributaries, in addition to compression. This lowers 4-year recurrence by about half.
  • Surgical ligation and stripping or phlebectomy, and perforator ablation in selected patients.
  • Iliac or femoral vein stenting for chronic outflow obstruction, by a vascular specialist.
• Skin grafting (split thickness graft or cultured grafts) for large ulcers that fail to heal after 6 months of correct treatment. Negative pressure wound therapy after debridement for large wounds.
• Analgesia: paracetamol 1 g orally 6 hourly, with a topical lidocaine, and avoid NSAIDs when possible. Pain after dressing removal is a sign to change the product or technique.
• Optimise general health: weight loss, glucose control, nutrition (protein 1.25 to 1.5 g/kg per day), stop smoking, mobilise, and manage heart failure and anaemia.
• Special groups:
  • Elderly: help with bandaging, arrange district nurse support, and review skin fragility.
  • Diabetes: confirm arterial supply and neuropathy status, since compression is risky in those with severe disease.
  • Mixed arterial and venous ulcers: reduced compression of about 20 to 30 mmHg under specialist supervision, with vascular assessment.
  • Pregnancy: use compression and elevation. Avoid sclerotherapy and pentoxifylline.
  • Renal impairment: adjust pentoxifylline and antibiotic doses.
  • Sickle cell disease: transfusion, hydroxycarbamide consideration, and specialist care, since ulcers heal slowly.
• Monitoring of healing: measure the area every 2 weeks. A reduction of 20 to 40% in 4 weeks predicts healing at 12 weeks. If not, reassess perfusion, infection, compression adherence, dressing allergy, nutrition, and the diagnosis, and take a biopsy.
• Prevention of recurrence: lifelong compression stockings, treatment of superficial reflux, skin care with emollient, weight control, calf exercises, and prompt treatment of cellulitis.
• Follow up: dressing changes weekly or twice weekly. Refer to a leg ulcer service, vascular surgery or dermatology for ulcers that are not reducing in size at 4 to 6 weeks, are larger than 10 cm, have been present for more than 6 months, show atypical features, or need venous intervention.