Venous leg ulcer

Definition
A venous leg ulcer is an open sore on the lower leg, usually between the ankle and knee, that occurs due to chronic venous insufficiency. It develops when damaged vein valves impair blood return, causing increased venous pressure and leakage of fluid and blood components into surrounding tissues, leading to skin breakdown.

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Causes and Pathophysiology

• Primary cause: Chronic venous insufficiency (CVI) due to valve incompetence in superficial, perforator, or deep veins

• Contributing factors:

  • History of deep vein thrombosis (post-thrombotic syndrome)

  • Varicose veins

  • Obesity

  • Leg injury or surgery

  • Reduced calf muscle pump function (immobility, muscle weakness)

• Pathophysiology:

  • Venous hypertension → capillary distension → increased permeability → leakage of plasma and red blood cells → fibrin deposition and inflammatory changes → tissue hypoxia and poor healing

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Risk Factors

• Age over 50

• Female sex

• Previous leg ulcer

• Family history of varicose veins or venous disease

• Sedentary lifestyle

• Pregnancy (multiple pregnancies increase risk)

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Clinical Features

• Location: Most commonly in the “gaiter” area (lower third of leg, above medial malleolus)

• Appearance:

  • Irregular margins

  • Shallow ulcer with granulating base

  • Surrounding skin often hyperpigmented (haemosiderin staining)

  • May have eczema, lipodermatosclerosis, atrophie blanche

• Symptoms:

  • Mild pain or discomfort (worse when standing, relieved by elevation)

  • Leg swelling

  • Heaviness or aching in legs

• Associated signs: Varicose veins, oedema, venous eczema, skin thickening

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Diagnosis

• Clinical examination: ulcer features and signs of venous disease

• Ankle–brachial pressure index (ABPI):

  • Performed before compression therapy to exclude significant arterial disease

  • ABPI ≥0.8 generally safe for compression; <0.8 indicates mixed arterial–venous disease

• Duplex ultrasound: assess venous reflux and obstruction

• Wound swab: only if clinical signs of infection (not for routine use)

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Treatment

1. General principles

• Treat underlying venous insufficiency

• Promote ulcer healing

• Prevent recurrence

2. Compression therapy (mainstay of treatment)

• Multilayer compression bandaging or compression stockings to reduce venous hypertension

• Only after ABPI confirms adequate arterial supply

• Applied by trained healthcare professional

3. Wound care

• Regular cleaning with saline or water

• Appropriate dressings to maintain moist wound environment (foam, hydrocolloid, alginate depending on exudate level)

• Debridement of necrotic tissue if present

4. Infection management

• Antibiotics only if cellulitis or clinical infection present

• Topical antimicrobials not routinely recommended

5. Pain management

• Paracetamol or NSAIDs if appropriate

6. Adjunctive measures

• Leg elevation to reduce oedema

• Exercise (especially ankle flexion and calf muscle exercises)

• Skin care to prevent eczema or dermatitis (emollients, topical steroids for inflammation)

7. Surgical/endovenous interventions

• For underlying venous reflux: endovenous laser therapy, radiofrequency ablation, foam sclerotherapy, or surgical ligation/stripping

• Can reduce recurrence risk

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Prognosis

• With proper compression therapy, ~60–70% heal within 12–24 weeks

• Recurrence rates are high (20–40% within 1 year) without ongoing preventive measures

• Lifelong compression hosiery is recommended after healing to prevent recurrence

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Prevention

• Continued use of graduated compression stockings after healing

• Weight management and regular exercise

• Avoid prolonged standing or sitting with legs dependent

• Elevate legs when resting

• Prompt treatment of venous disease