Key Facts

Chronic leg ulcers are extremely common, particularly in elderly patients. Accurate diagnosis of the underlying cause is essential as management differs fundamentally between venous and arterial ulcers. Compression therapy is the mainstay for venous ulcers but is dangerous in arterial disease.

Epidemiology

• Prevalence: ~1% of UK adults; increases with age (~3.6% in >65s)
• F > M
• Venous ulcers: ~70% of all leg ulcers
• Significant impact on quality of life and healthcare costs (~£1 billion/year NHS)

Aetiology

• Venous (~70%): chronic venous insufficiency → venous hypertension
• Arterial (~15%): peripheral arterial disease → ischaemia
• Mixed (~10–15%): combined venous and arterial disease
• Other: diabetic (neuropathic), vasculitic, malignant (Marjolin's), pyoderma gangrenosum, calciphylaxis

Pathophysiology

Venous:

• Incompetent valves → venous reflux → sustained venous hypertension → capillary leak → fibrin cuff deposition → tissue hypoxia → ulceration
• White cell trapping hypothesis: leucocytes trapped in capillaries → tissue damage

Arterial:

• Atherosclerotic occlusion → reduced limb perfusion → tissue ischaemia → necrosis → ulceration

Venous Ulcers

• Location: gaiter area (between ankle and mid-calf), especially medial malleolus
• Appearance: shallow, irregular, sloping edges; granulating or fibrinous base
• Surrounding skin: venous eczema, haemosiderin staining (brown), lipodermatosclerosis (inverted champagne bottle), atrophie blanche, varicose veins, oedema
• Pain: mild–moderate, improved by elevation

Arterial Ulcers

• Location: distal — toes, dorsum of foot, heel, lateral malleolus; pressure points
• Appearance: deep, punched-out, well-defined edges; pale/necrotic base
• Surrounding skin: pale, shiny, hairless; absent/reduced pulses; prolonged capillary refill
• Pain: severe; worse on elevation, improved by dependency (hanging legs off bed)
• Claudication/rest pain history

Mixed Ulcers

• Features of both venous and arterial disease
• Require modified (reduced) compression

Red Flags

• Non-healing ulcer >4–6 weeks despite appropriate treatment — biopsy to exclude SCC (Marjolin's ulcer)
• Rapidly enlarging, undermined edges — consider pyoderma gangrenosum
• Very painful ulcer with livedo reticularis — consider vasculitis
• Calciphylaxis in dialysis/CKD patients — extremely painful, rapidly progressive

Bedside

• ABPI (ankle-brachial pressure index): essential before applying compression

  • 0.8: venous — safe for full compression

  • 0.5–0.8: mixed — reduced/modified compression with specialist input
  • <0.5: significant arterial disease — NO compression; vascular referral

  • 1.3: calcified vessels (diabetes, CKD) — unreliable; use alternative assessment

• Wound assessment: size, depth, base, edges, surrounding skin; photograph and document
• Monofilament test: diabetic neuropathy assessment

Bloods

• FBC: anaemia, infection
• CRP/ESR: infection, inflammation, vasculitis
• HbA1c: diabetes screen
• Albumin: nutritional status (hypoalbuminaemia impairs healing)
• U&Es: renal function
• Rheumatoid factor, ANA, ANCA: if vasculitic ulcer suspected

Imaging

• Venous duplex USS: assess venous incompetence — guide intervention
• Arterial duplex/CT angiography: if ABPI <0.8 — assess for revascularisation

Special Tests

• Wound swab: only if clinical signs of infection (not routine for colonisation)
• Biopsy: non-healing ulcer >4–6 weeks — exclude malignancy, vasculitis, atypical infection
• Patch testing: if suspected contact allergy to dressings/topical preparations

Venous Ulcers

Compression therapy (ABPI >0.8):

• Multilayer compression bandaging: first-line — aims for 40 mmHg at ankle
• Compression hosiery (class 3): for prevention of recurrence after healing

Wound care:

• Simple non-adherent dressings: changed as needed
• Treat venous eczema: emollients, topical corticosteroids short-term
• Avoid sensitising topical agents: lanolin, neomycin (high contact allergy rates in leg ulcer patients)

Adjunctive:

• Pentoxifylline 400 mg TDS: improves venous ulcer healing — NICE recommended
• Leg elevation above heart level: whenever resting

Surgical:

• Venous intervention: endovenous ablation, foam sclerotherapy (EVRA trial — early intervention improves healing)
• Skin grafting: for large, non-healing ulcers

Arterial Ulcers

• Vascular surgery referral: revascularisation (angioplasty, bypass) is definitive
• NO compression until arterial disease excluded/treated
• Risk factor modification: smoking cessation, statin, antiplatelet, BP control
• Wound care: moist wound healing, debridement, infection management

Mixed Ulcers (ABPI 0.5–0.8)

• Modified/reduced compression: with specialist supervision
• Vascular assessment: may benefit from revascularisation

Referral Criteria

• Tissue viability nurse: all chronic leg ulcers
• Vascular surgery: ABPI <0.8, arterial ulcer, failed conservative management
• Dermatology: atypical ulcer, suspected vasculitis/pyoderma gangrenosum, biopsy needed
• Diabetes team: diabetic foot ulcer

• Venous ulcers: ~70% heal within 12 weeks with compression; recurrence ~30% within 1 year without compression hosiery
• EVRA trial: early venous intervention accelerates healing
• Arterial ulcers: healing dependent on revascularisation; poor prognosis without intervention
• Marjolin's ulcer: aggressive SCC — 5-year recurrence ~30%, metastasis ~30%
• Mixed ulcers: slower healing; require balanced approach
• Prevention of recurrence: lifelong compression hosiery, leg elevation, weight management

Leg Ulcer Comparison

ABPI Interpretation