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ABC of Vascular Disease

Venous Ulcers

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1. What is a venous ulcer?
A venous ulcer is damage and loss of skin above the ankle that is the result of a problem with the veins in the leg.  Venous ulcers are quite common, difficult to heal and often recur.

2. What is the problem with the veins?
Veins are part of the blood circulation system.  The veins carry blood back to the heart so that it can be pumped into the arteries.  Leg veins have flexible valves inside that ensure the blood can only flow back to the heart, especially when standing and walking.  The most important veins are deep inside the leg, surrounded by the muscles.  During walking, the rhythmic contraction of the leg muscles squeezes these veins and actually pumps the blood back to the heart!  A number of problems with the veins can cause this pump to fail and if this happens the venous blood pools in the legs on standing and walking and the blood pressure in the veins increases.  Over a number of years the excessive pressure damages the skin and eventually and an ulcer develops.

3. How do you diagnose a venous ulcer?

A venous ulcer has a characteristic appearance:
bulletMost commonly situated on the lower leg just above the ankle.
bulletUsually surrounded by brown-stained skin.
bulletVaricose veins are often visible as well.
bulletRest of the foot and heel usually look normal.
bulletThe ulcer can be of any size.
bulletThe ulcer is often green and smelly because of infection.

About two thirds of leg ulcers with this appearance are venous ulcers.  To diagnose problem with the veins that has caused the ulcer requires a special test using ultrasound.  A patient with a new leg ulcer should be referred to a specialist for expert assessment.

4. What will happen if I have a venous ulcer and I do nothing about it?
A venous ulcer will not usually heal without expert advice and treatment.  Unless it is kept clean and dressed regularly a venous ulcer can become infected and get much larger very quickly.  Venous ulcers can be very painful and limit mobility and quality of life.  The longer you have a venous ulcer the more damage that is done to the skin of the leg and the more difficult is is to heal, even with expert advice.

 5. How do you cure a venous ulcer?
There are three important principles involved in effective treatment of a venous ulcer:

  1. Keep the ulcer clean and dressed regularly to prevent infection and promote healing.

  2. Have the cause investigated by a specialist.

  3. Treat the underlying cause effectively to allow healing and prevent recurrence.

6. What treatments are there for venous ulcers?
There are three effective forms of treatment for venous ulcers:

  1. Elevate the affected leg for as long as possible to prevent pooling of the blood and allow healing.

  2. Apply special compression bandages to the leg for support when standing and walking.

  3. Surgically remove any leaky veins that are contributing to the problem.

7. Who will do the compression bandaging?
The compression bandaging must done by a person who has been trained to do it properly.  This will usually be a district nurse, or a nurse in a leg ulcer clinic.  If the bandage is put on too loosely it doesn't work; if it is put on too tightly it may make the ulcer worse or cause other ulcers to appear. 

8.  What if I need surgery?
If the specialist assessment shows that there are problems with the veins under the skin then your specialist may recommend surgery to remove these veins or the prevent the blood flowing the wrong way in these veins.  For more details see varicose veins. 

9. How long does it take for the ulcer to heal?
The time taken for a leg ulcer to heal is difficult to predict. The following factors are important for healing:

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Small ulcer

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Effective compression bandaging

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Treatment of underlying venous problem

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Skin grafting

Some ulcers will heal in a few days, others take weeks or months and some never heal.

10. What can I do to speed up my recovery?
Common sense tells you that a good diet, plenty of rest, and regular dressings will allow the healing process do its job.

12. Will I need to come back to hospital?
It is usual for patients with leg ulcers to be reviewed at intervals in a special leg ulcer clinic.  This is to ensure that the treatment is effective and no complications have developed such as infection.  

13. Will the ulcer come back?
Unfortunately, in many patients venous ulcers will recur either at the same of different sites.  It is therefore very important that treatment continues after the first ulcer has healed, especially if the underlying problem with the veins cannot be treated surgically.  The most usual form of long term treatment is the use of graduated compression socks.

S.R.Dodds 2006

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