Venous leg ulcer

A venous leg ulcer is a long-lasting (chronic) sore on the leg. It usually develops on the inside of the leg, just above the ankle.

A venous leg ulcer is an open sore in the skin, and it's often painful. What marks it out is that it takes more than a month to heal. The skin changes can look different on different skin colours.

If you have a venous leg ulcer, you may also have:

• swollen ankles (oedema)
• discolouration and darkening of the skin around the ulcer
• hardened skin around the ulcer
• a heavy feeling in your legs
• aching or swelling in your legs
• red, flaky, scaly and itchy skin on your legs (varicose eczema)
• swollen and enlarged veins on your legs (varicose veins)

A venous leg ulcer can easily get a bacterial infection.

The signs of an infected leg ulcer can include:

• worsening pain
• a green or unpleasant discharge coming from the ulcer
• a high temperature (fever)

If you think you have a venous leg ulcer, see a doctor. The ulcer is unlikely to heal without specialist treatment.

The doctor will ask about your symptoms and examine the affected leg to help diagnose a venous leg ulcer. They may also need to do some other tests.

Your doctor or practice nurse will ask whether you have any other symptoms that go with a venous leg ulcer, such as:

• swelling in your ankles
• discoloured or hard skin

They'll also try to find the cause of the ulcer. To do this, they'll ask about underlying conditions or earlier injuries, such as:

• diabetes
• deep vein thrombosis (DVT)
• injury or surgery in the affected leg
• a previous leg ulcer

Your leg will be examined while you're standing up and while you're lying down. The doctor or nurse will also feel the pulse at your ankles, to make sure the arteries in your leg are working properly.

Your doctor or nurse will do a test called the Doppler study, which helps rule out peripheral arterial disease (a condition affecting the arteries). They measure the blood pressure in the arteries at your ankles and compare it with the pressure in your arms. If you have peripheral arterial disease, the pressure in your ankles will be lower than in your arms.

This check matters because the main treatment for a venous leg ulcer is compression bandages or stockings, which improve the circulation in the veins of your legs. It's not safe to apply compression if the ankle artery pressures are low.

Sometimes your doctor or nurse may decide to send you to a specialist in conditions affecting the blood vessels, called a vascular specialist. This can happen if they aren't sure about your diagnosis, or if they suspect your venous leg ulcer may be caused by:

• artery diseases
• diabetes
• rheumatoid arthritis

The specialist will talk with you about your medical history and examine you. They may also need to arrange further tests to plan your treatment.

With treatment, most venous leg ulcers heal within 6 months.

The first step is to clear any debris or dead tissue from the venous leg ulcer and put on a suitable dressing. This gives the ulcer the best conditions to heal.

Your ulcer will be covered with a simple dressing that doesn't stick to the wound. It usually needs changing once a week. Many people find they can clean and dress the ulcer themselves, with a nurse keeping an eye on how they're doing.

If you have a venous leg ulcer, your nurse will put a firm compression bandage over the affected leg. This improves the circulation in your leg veins and treats the swelling. The bandage squeezes your leg and encourages blood to flow upwards, towards your heart.

Many different types of bandage or elastic stockings are used to treat venous leg ulcers, and they may be made in 2 to 4 different layers.

The bandage is changed once a week, at the same time as the dressing.

When compression bandages are first put on an unhealthy ulcer, it's usually painful.

Ideally, your doctor should prescribe paracetamol or another painkiller for you. You can get paracetamol from your local pharmacist or your doctor. The pain will ease once the ulcer starts to heal.

Wear your compression bandage exactly as instructed. If you have any problems, it's usually best to contact your nurse rather than try to remove it yourself. If the bandage feels a little too tight and is uncomfortable in bed at night, getting up for a short walk will usually help.

But you'll need to cut the bandage off if:

• you get severe pain at the front of your ankle
• you get severe pain on the top of your foot
• your toes become blue and swollen

Once the bandage is off, keep your leg raised and contact your doctor or nurse as soon as possible.

In some clinics, specialist teams are using new alternatives to compression bandages. These include:

• special stockings
• other compressive devices

These may not be available in every clinic. Your specialist can advise you whether a different approach may help.

A venous leg ulcer often comes with swelling of the feet and ankles (oedema), which is caused by fluid. Compression bandages can control this.

Some people with venous leg ulcers also get a rash, with scaly and itchy skin. Often this is varicose eczema, which can be treated with a moisturiser (emollient). Sometimes a mild corticosteroid cream or ointment can help as well. In rare cases, you may need to be referred to a dermatologist (skin specialist) for treatment.

Itchy skin can also sometimes come from an allergic reaction to the dressings or creams your nurse applies. If this happens, you may need to be tested for allergies.

Try not to scratch your legs when they itch. Scratching damages the skin and may lead to further ulcers.

• walk regularly and stay active
• keep your affected leg raised, with your toes level with your eyes
• move your feet up and down, and rotate them at the ankles (this can help improve circulation)
• eat a healthy diet
• cut down on alcohol
• wear comfortable shoes that fit well

If your venous leg ulcer becomes infected, it should still be cleaned and dressed as usual. You should also keep your leg raised most of the time, and you'll be prescribed a 7-day course of antibiotics.

The antibiotics are there to clear the infection. But they don't heal ulcers, so they should only be used in short courses to treat an infected ulcer.

Having had a venous leg ulcer once, you could get another one. The best way to prevent this is to wear compression stockings whenever you're out of bed. Your nurse will help you find a stocking that fits properly and that you can manage on your own.

There are several accessories that can help you put the stockings on and take them off.

A venous leg ulcer can form after a minor injury when the blood isn't circulating properly in the veins of your leg. When this happens, the pressure inside the veins goes up.

That high pressure doesn't let up, and over time it can damage the tiny blood vessels in your skin and make the skin fragile. So even a knock or a scratch can break it and leave an ulcer.

If you don't have treatment to improve the circulation in your legs, the ulcer may not heal.

Several things can raise your risk of getting a venous leg ulcer. These are the main ones:

• obesity or being overweight, because this increases the pressure in the leg veins
• difficulty walking, because this can weaken the calf muscles, which can affect circulation in the leg veins
• previous deep vein thrombosis (DVT), because blood clots that develop in the leg can damage valves in the veins
• varicose veins, which are swollen and enlarged veins caused by malfunctioning valves
• previous injury to the leg, such as a broken or fractured bone, which may cause DVT or affect your walking
• previous surgery to the leg, such as a hip replacement or knee replacement, which can prevent you from moving about
• increasing age, because some people find it harder to move around as they get older, particularly if they suffer from arthritis

There are some things you can do to help prevent venous leg ulcers. For example, you could:

• wear compression stockings, which your doctor may recommend
• manage your weight (if you're obese or overweight, losing weight can help treat and prevent venous leg ulcers)

The people most at risk of developing a venous leg ulcer are those who have had a leg ulcer before.