Ulcers are open sores/wounds caused by breaks in the continuity of the skin.¹ There are several causes of ulcers, but the most common causes are trauma or injuries, unrelieved pressure, infections, vascular problems (e.g., arterial disease, venous ulcers), diabetes and cancers.¹

Chronic ulcers, also known as non-healing ulcers, are sores/wounds that generally tend to show no or minimal signs of healing for longer than 4-6 weeks.^1,2 An estimated 1% to 2% of the entire population in the developed world may suffer from a chronic ulcer/wound at least once in their lifetime.² 

Lower extremities (legs) are one of the most common sites where chronic ulcers may develop.^1,2 Estimates suggest that the number of people suffering from chronic lower extremity or leg ulcers is rising due to risk factors such as the rising ageing population and an increase in smoking, obesity and diabetes.³ 

Chronic leg ulcers can significantly impact the quality of life of the individuals suffering from them.^1,2 Management of chronic leg ulcers is individually variable and relies on treating the primarily underlying cause through appropriate medical/surgical attention while providing symptomatic comfort for reducing disruptions to quality of life and maintaining aseptic precautions.^1,2 In the long term, such ulcers can cause chronic pain, eventual loss of mobility or function, prolonged hospitalisation, secondary infection, increased morbidity (chances of falling ill) and increased mortality.^1,2,3

Types of chronic leg ulcers

As discussed above leg ulcers may have various causes such as diabetes, blood vessel issues, mechanical trauma, infections (e.g., syphilis, tuberculosis), pyoderma gangrenosum, etc.^1-3 However, discussing all of these is beyond the scope of this article. Thus, let’s focus on the most common types of chronic leg ulcers:

Venous ulcers

Venous ulcers are the most common type of ulcers reported in the legs, making up for almost 90% of cases reported in the UK for leg ulcers. Another commonly used term for venous ulcers is “varicose ulcers”.¹ 

Venous ulcers are generally the result of high blood pressure over a long time in the lower extremities veins. This continuously high pressure in the veins can gradually damage the veins underneath our skin, which following minor injuries such as scratches or knocks to these damaged veins under your skin, can form an ulcer.⁴ Venous ulcers are commonly known to occur on the inside of the lower extremity (legs), just above the ankle.⁴

Common risk factors that might predispose individuals to develop venous ulcers are obesity, older age, individuals with difficulty in walking for any reason (causing reduced circulation in legs, resulting in increased blood pressure), varicose veins, and a history of blood clots in the legs.⁴ 

Arterial ulcers

Arteries commonly supply blood rich in oxygen and other nutrients to our entire body, including our legs.^1,3,5 When arteries are blocked or narrowed, the blood supply decreases, causing a reduction of essential supplies (oxygen and other nutrients), creating an ischaemic (starving-like) effect on the local peripheral areas such as the toes or heels.^3,5

Chronic arterial leg ulcers may be caused by spontaneous local death of these peripheral areas (toes, heels) due to arterial diseases or more commonly by minor injuries which heal slower than usual due to pre-existing inadequate blood supply.^1,5

Some common predisposing factors of arterial ulcers are diabetes, smoking, high levels of cholesterol in the blood, high blood pressure, obesity, history of clotting disorders, and history of any other circulatory disorder such as heart disease or peripheral vascular disease.^3,5

Diabetic ulcers

Diabetic ulcers are a common type of foot ulceration and are one of the major causes of amputations. The lifetime risk of developing a foot ulcer in patients with diabetes is 33%.^3,5,6 National research in the UK, estimates that 10% of people with diabetes can develop a diabetic foot ulcer at some point.

Individuals living with diabetes are highly prone to arterial diseases and neuropathy (nerve damage causing numbness), both of which can cause ulcers to develop in weight-bearing areas of the feet such as the underside of the toes or heels and tip of the toes.⁶ Common risk factors for diabetic foot ulcers include uncontrolled blood sugar levels, uncontrolled diabetes, and diabetic individuals with flat feet.^3,5,6

Pressure ulcers

 Pressure ulcers are commonly caused due to unrelieved pressure. This unrelieved pressure over long periods, can obstruct blood flow, which eventually causes a starving-like effect, resulting in local tissue injury and death.⁷ Pressure ulcers are commonly seen over bony areas such as the heels or upper side of the buttocks/lower back areas which are subject to high pressure on a daily basis.^3,7

They occur more commonly in the elderly population, especially among patients who are incontinent, paralysed, debilitated, have difficulty moving or have restricted movement, hence why pressure ulcers are also often called bed sores.⁷

Research on pressure ulcers shows that patients above the age of 70 make up for a large percentage of those at risk of developing pressure ulcers. Other risk factors include hip fractures, smoking, dry skin, individuals suffering from chronic or terminal illnesses, and hospitalised individuals.⁷ Secondary infection, septicaemia and eventually increased chances of death are major complications of these types of ulcers.^3,7

Signs and symptoms

Signs and symptoms vary based on the different types and underlying causes of the ulceration. However, the following are some of the most common signs and symptoms seen in the most common types of chronic leg ulcers:^1-7

• A long-lasting ulcer/wound that heals slowly over a long period (more than 4-6 weeks)
• Pain and swelling of the affected area and the legs
• Itchiness in and around the affected area
• Venous ulcers may have hardened or discoloured skin around the ulcer along with a foul-smelling discharge from the wound
• Arterial ulcers are typically more painful at night, and typically bleed less or bleed only on being touched or knocked
• Surrounding skin in arterial ulcers appears cool, pale, shiny and bluish with loss of leg hair and a faint or absent ankle pulse
• In addition to skin discolouration, discharge of pus or blood, pain, and swelling; diabetic foot ulcers may also be accompanied by a very foul smell and redness
• Pressure ulcers like others also cause pain and itchiness but, generally appear as discoloured red/purple/brown patches that do not change colour on being pressed, the skin in and around it feels warm, spongy, or hard

Diagnosis of chronic leg ulcers

Diagnosis of chronic leg ulcers involves clinical assessment, carried out through patient history and examination to assess and identify the features of the ulceration.³ The history and examination include going through the known signs and symptoms associated with the different types of chronic leg ulcers and identifying which subset of clinical features, signs and symptoms the ulceration may closely identify with, to administer treatment accordingly.

Blood tests including blood counts, blood sugar and fat levels, kidney and liver function tests and urine tests may commonly be needed when diagnosing and treating chronic leg ulcers. This list is not exhaustive and depending on the suspected underlying conditions additional investigations may be required. For example, for diagnosing clotting disorders, activated partial thromboplastin time may be required, which may not be essential in individuals where clotting disorders are not suspected.³ 

Furthermore, additional investigations such as Doppler ultrasound imaging, magnetic resonance angiography, and digital subtraction angiography to look at blood vessels may also be required.³ In cases where infections are suspected, testing for bacteria by swabbing the wound may be helpful.³

A biopsy (surgically removing a part of the ulcer and surrounding area as needed) followed by an appropriate examination of the sample may also be needed for diagnosis, treatment and to rule out cancer.^3-7

Further research regarding genetic testing is currently underway, which would help identify patients at high risk of developing chronic leg ulcers with a simple blood test.⁸

Treatment, management, and prevention

Treatment of chronic leg ulcers is most effective by treating the underlying cause, providing symptomatic comfort for reducing discomfort to the patient’s quality of life, and maintaining aseptic precautions. 

The rate of recovery for each sub-type varies, but with appropriate care and intervention, patients with chronic leg ulcers can make a full recovery over time.^1-8 Following are some common treatments, management, and prevention for common chronic leg ulcers.

Venous ulcer

• Cleaning and dressing the ulcer 1-3 times mostly with a compression bandage to improve circulation
• Leg elevation for 30 minutes around 3-4 times a day
• Regular exercise such as walking
• Emollient and occasionally mild corticosteroids for itchy skin
• Painkillers and antibiotics (as needed)
• Preventive measures – diet and exercise to reduce weight (if needed), moderating alcohol consumption and smoking habits^1,3,4

Arterial ulcer

• Regularly cleaning and dressing the wound to keep it moist
• Physical and/or chemical removal of debris from the wound (to remove dead tissue)
• Antibiotics if needed
• Surgical interventions – skin grafting to promote healing, surgery to repair blood circulation in the legs
• Lifestyle changes – moderating alcohol consumption and smoking habits, changing your diet to reduce blood lipid and cholesterol levels, and controlling blood sugar^1,3,5

Diabetic ulcers

• Treatment can be multidisciplinary requiring expertise across different specialties such as endocrinology, podiatry, neurology, wound care, diabetes education, orthopaedics, and vascular surgery
• Cleaning and dressing the wound along with draining any pus or fluid and removing debris/dead tissue is essential
• Controlling blood sugar levels
• Treating secondary infection as needed
• Additional treatments – hyperbaric oxygen therapy, negative compression, surgical intervention (to remove the ulcers, skin grafting, amputation) as needed
• Preventive measures – smoking cessation, regular toe-nail trimming, daily exercise, treatment of non-ulcerative conditions, reducing pressure on the foot through comfortable footwear, patient education and counselling^3,8

Pressure ulcers

• Removing pressure on the ulcers by changing positions and keeping up movement regularly
• Cleaning and dressing the ulcer
• Creams and ointments for the wound
• Antibiotics (as needed)
• Using specially designed mattresses and cushions
• Surgery may be required in severe cases to clean and close the wound^5,7

Complications

While complications may vary with the underlying cause, some common complications of chronic leg ulcers include

• chronic pain
• serious infections and septicaemias
• increased chances of death
• impaired mobility
• transformation into cancer
• negative impact on quality of life
  • psychological distress
  • loss of independence
  • social isolation^1-8

Nonetheless, when treated in time chronic leg ulcers in most cases are manageable and may develop minimal complications.^1-8

FAQs

What are some common risk factors that may cause chronic leg ulcers?

Some common risk factors include smoking, higher or uncontrolled alcohol consumption, obesity or being overweight, pre-existing heart/blood vessel/clotting diseases, uncontrolled blood sugar, restricted movement, older age, high levels of cholesterol in the blood, numbness or loss of sensation in peripheral areas (toes, heels) and high blood pressure.^1-8

Are leg ulcers treatable?

Yes, they are treatable. Treatment commonly includes finding and treating the underlying cause, providing symptomatic comfort for reducing discomfort in quality of life and maintaining septic precautions. Although the prognosis for chronic leg ulcer is highly variable, with appropriate medical care and attention a good amount of recovery may be possible.^1-8

What should I do if I have or suspect that I may have a leg ulcer?

If you suspect that you may have a leg ulcer, contact your local GP surgery at the earliest. Your GP can examine your leg, perform necessary tests, start treatment and refer you appropriately for specialist care.

Summary

Chronic leg ulcers are stubborn sores that don't heal within 4-6 weeks and often appear on the lower legs. They're usually caused by factors like trauma, persistent pressure, infections, blood flow issues, diabetes, or cancer. These ulcers can seriously affect one's quality of life.

The most common types are venous ulcers, which are due to long-term high blood pressure in the leg veins; arterial ulcers, caused by reduced blood flow; diabetic ulcers, often found on the feet; and pressure ulcers, resulting from extended pressure on bony areas. Symptoms include slow-healing wounds, pain, swelling, itchiness, and changes in skin colour. To diagnose these ulcers, doctors assess symptoms, conduct blood tests, use imaging techniques, and sometimes perform biopsies.

Treatment focuses on addressing the root cause, keeping the wound clean, and easing discomfort, with methods like wound cleaning, dressing, antibiotics, and surgery. Preventive measures include lifestyle changes and patient education. While complications like infections and mobility issues can arise, prompt and proper treatment can significantly improve outcomes.