Overview

Perhaps you have been diagnosed with a leg ulcer or maybe have been told you are at risk of leg ulcers. Whilst a worrying situation to be in, leg ulcers are very common and treatments do exist. Leg ulcers are defined as a break in the skin commonly occurring after a minor injury, which has not healed in two weeks.^1,2 In this article, we will cover leg ulcers in more detail, focusing on venous ulcers, and more.

What are leg ulcers?

Leg ulcers are breaks in the skin, commonly occurring following a minor injury such as a scratch or knocking your leg against something, which does not heal in two weeks.^1,2 They are increasingly common with age. Around 1 in 50 people over the age of 80 have venous ulcer.² 1% of the elderly and middle-aged population have chronic leg ulcers.³ Some people are more at risk than others. These risk factors will be explored later. 

Leg ulcers can have a significant impact on your quality of life due to the associated symptoms and complications such as pain, odour, reduced mobility and infection.⁴ They are also costly to the NHS, with an annual cost of about £300 million.⁴

Types of leg ulcers

The following are types of leg ulcers, the most common being venous:⁵

• Venous ulcers (80% of all ulcers)
• Arterial disease (15%) 
• Other causes e.g. diabetes or rheumatoid arthritis (5%)

Ulcers can also be categorised as:³

• Acute–these ulcers heal within four weeks e.g. wounds following surgery or trauma
• Chronic–these remain after four weeks

Causes of venous leg ulcers

As venous ulcers are the most common type of ulcer, we will focus on venous ulcers. Venous ulcers are caused by problems in the blood flow in the veins in the legs.^3,5 Veins in the leg pump blood upwards back to the heart, fighting gravity. Two factors facilitate this:³

• One-way valves in the veins prevent the backward flow of blood
• Calf muscles contract during exercise, which squeezes the blood through the veins 

Sometimes this system does not work as it should due to an obstruction in the veins, such as a clot, reduced muscle contractions and ineffective valve action.^3,5 The result is blood pooling in the leg veins particularly when you are standing or sitting, which can lead to very high pressures. 

The high venous pressure leads to fibrin formation, a protein involved in blood clotting, to settle in the small blood vessels known as capillaries. Oxygen and nutrients are no longer delivered to muscle and skin tissue, resulting in the death of tissue cells and ulceration.³ Thereafter, minor injuries can develop into ulcers. The one-way valve system and contraction of calf muscles allow the flow of blood upwards back to the heart, against gravity.⁶

A number of risk factors have been listed below:^1,2,3,7 

• Previous leg ulcer, recurrence is very common
• Obesity
• Increasing age 
• Varicose veins - large and swollen veins on the back of legs, with a twisted appearance
• Previous DVT
• Immobility 
• Osteoarthritis
• Previous leg injury
• Recent hip or knee replacement surgery 
• Multiple pregnancies

Symptoms of venous leg ulcers

If you suspect that you may have a venous ulcer, you should see your doctor. Listed below are common symptoms and features:^2,3 

• Located above the ankle, medial side of the leg
• Ankle swelling (oedema) 
• The skin surrounding the ulcer can darken, become discoloured and harden (lipodermatosclerosis) 
• Legs may look like an upside-down champagne bottle
• Heavy legs
• Usually, painless ulcers, unless infected
• Red, flaky, scaly and itchy skin surrounding ulcer (varicose eczema)
• Large, swollen and twisted veins on the back of legs (varicose veins)

Diagnosis of venous leg ulcers

Diagnosis is based on the history, symptoms and examination findings you present with.^1,2 It is important for physicians to rule out arterial disease when treating venous ulcers which they may do so using a doppler study, which measures the blood pressure in the arteries in your leg compared to those in your arm.² It is common to present with a mix of venous and arterial disease.

Management of venous leg ulcers

Management involves the following:

Proper wound care and dressing

• Cleaning the wound (debridement) and changing dressings weekly. Usually done by district or practice nurse.^1,2

Compression therapy

• Must not be used if there is an existing arterial disease as it may compromise blood flow, resulting in blue discolouration, paleness and pain in the legs. You should see a doctor if this happens³ 
• Compression stockings squeeze the legs, aiding the flow of venous blood back to the heart⁵

Lifestyle measures

• Leg elevation can help aid the flow of blood in the veins back up to the heart. Exercise can also facilitate this due to muscle contractions in the calf during exercise² 
• Quitting smoking, moderating alcohol intake, and using appropriate footwear is also important in the management. You can also join a local healthy leg club e.g. Lindsay Leg Club Foundation²
• Exercise and weight loss management²

Associated symptoms such as varicose eczema can be treated with emollients and mild corticosteroids.² Your doctor may also consider giving you a medication called pentoxifylline to improve blood flow and aid in ulcer healing.^1,8 

It is important to have regular follow-ups with a healthcare professional to assess the ulcer. If there is little or no healing after two weeks of treatment, you may be referred to a specialist.¹

Occasionally, very large ulcers that are not treatable with the above measures, may need surgery such as a skin graft or the veins may need to be operated on.⁵ Surgery on the leg veins such as ultrasound-guided sclerotherapy or endovascular laser treatment may help with ulcer healing.³ Complications and prognosis of venous leg ulcers.

If you find that your ulcer is becoming more painful, shows a green/yellow discharge, becomes smelly or you have developed a fever, you must see your doctor as you may have developed an infection. These are treated with antibiotics.

Venous ulcers can take months to heal. There is a wide variation in reports of how long this can be.¹ It could take 3-4 months to heal.² However, some reports show that at 6 months, only 45% of ulcers have healed, of those treated in the community.¹ Unfortunately, if you have had a venous ulcer in the past, the chances are it may recur. 

There are some things you can do to reduce the risk of recurrence such as using below-the-knee compression stockings when not in bed, elevating your legs when sat as well as maintaining a healthy weight and exercising regularly.^1,2 Treatment of any underlying condition e.g. varicose veins can reduce your risk of developing ulcers.²

A brief overview of arterial and diabetic leg ulcers 

Whilst venous ulcers make up 80% of all ulcers, about 15% are due to arterial disease.⁵ Arterial ulcers are caused by not enough blood being delivered to the leg; this is usually due to a blockage in the arteries known as atherosclerosis, shown in the diagram below.³ Atherosclerosis is a build-up of fats which narrows the arteries.¹⁰ 

Conditions such as diabetes, smoking, high blood pressure, obesity, and others can increase your risk of developing atherosclerosis and subsequently, arterial ulcers.¹⁰ To assess the arterial circulation in your feet, your doctor may measure your ankle brachial pressure index (ABPI), mentioned earlier in the article.³

Diabetic ulcers are common in people who have poorly controlled diabetes and poor foot care. These ulcers are caused by a combination of arterial disease and nerve damage to small nerves in the feet (diabetic neuropathy).³ The nerve damage means you may not feel and become aware of any injuries to your feet which can then develop into ulcers.³ It is important to know which type of ulcer you have as the management differs

The table below summarises some of the key differences between various types of leg ulcers:^2,3,11

FAQs

How can I prevent leg ulcers?

Lifestyle e.g. being active, healthy diet & weight, leg elevation (venous ulcers), good diabetic control & foot care (diabetic ulcers). Manage underlying conditions.

How common are leg ulcers?

Leg ulcers are very common, and the risk increases with age. One in fifty over age 80 has a venous ulcer.² Around 1% of the elderly and middle-aged population have chronic leg ulcers.³ 

What can I expect if I have leg ulcers?

• Venous ulcers –ankle swelling along with itchy, hardened and discoured skin. Arterial ulcers –painful when active, especially when legs are elevated. Poor circulation to your legs can cause pale, pulseless and cold legs
• Diabetic ulcers— these are present over pressure points. It is often associated with poor diabetic control and poor foot care

When should I see a doctor?

You should see a doctor if you:

• Suspect you may have ulcer 
• Suspect ulcer is infected (pain, green/yellow discharge, fever)

Summary 

Whilst we have focused on venous leg ulcers in this article due to them accounting for a large portion of ulcers, arterial and diabetic leg ulcers are important to highlight. The key distinguishing features between these leg ulcers can be found in the table above. Whilst ulcers can be difficult to cope with and take a long time to heal, they can be treated with the help of your doctor and other healthcare professionals.

 Lifestyle changes as well as other treatments are dependent on the type of leg ulcer you have. It is important to note that if you have one ulcer, you are at risk of having a recurrence. Always get in contact with your doctor if you suspect you may have an ulcer or if you suspect the ulcer is infected.