Venous Leg Ulcers

venous leg ulcer

Venous leg ulcers are a common problem in older people. They are mostly treated by compression bandages, applied correctly. Keep as active as possible but elevate your leg when you are resting.

What do you understand by venous leg ulcer?

A skin ulcer is where an area of skin has broken down and you can see the underlying flesh. Venous leg ulcers are the most common type of skin ulcer. They mainly occur just above the ankle. They usually affect older people and are more common in women. Venous leg ulcers can be painless but some are painful. Without treatment, an ulcer may become larger and cause problems in the leg. Skin inflammation (dermatitis) sometimes develops around a venous ulcer.

Non-venous skin ulcers are less common. For example, a skin ulcer may be caused by poor circulation due to narrowed arteries in the leg, problems with nerves that supply the skin, or other problems. The treatment for non-venous ulcers is different to that of venous ulcers.

How is venous leg ulcers caused?

They are caused by increased pressure of blood in the veins of the lower leg, causing fluid to ooze out of the veins beneath the skin. This causes swelling, thickening and damage to the skin. The damaged skin may eventually break down to form an ulcer.

How do you diagnose a venous ulcer?

Generally, diagnosed by its appearance. To rule out poor circulation as a cause, it is usual for a doctor or nurse to check the blood pressure in the ankle and in the arm. The ankle blood pressure reading is divided by the arm blood pressure reading to give a blood pressure ratio called the Ankle Brachial Pressure Index (ABPI). If the ratio is low (less than 0.8) it indicates that the cause of the ulcer is likely to be poor circulation (peripheral vascular disease) rather than venous problems. This is very important to know as the treatments are very different. An ABPI may be checked every six months or so to make sure the circulation to the legs remains good.

Certain blood and urine tests may also be done to rule out conditions such as anaemia, diabetes, kidney problems and rheumatoid arthritis which may cause or aggravate certain types of skin ulcer.

In complicated cases you may need to have a scan (ultrasound, CT or MRI) to produce a detailed map of the blood circulation in your leg.

How are venous leg ulcers treated?

The ulcer is dressed by a medical professional every week or so. The wound is cleaned when the dressing is changed - normally with ordinary tap water. However, an ulcer is unlikely to heal with just dressings. In addition to a dressing, the following treatments help the ulcer to heal.

  • Compression bandagingis the most important part of treatment. The aim is to counteract the raised pressure in the leg veins. This gives the best chance for the ulcer to heal. The common method is for a nurse to put on 2-4 layers of bandages over the dressing. When the bandages are put on, the pressure is put highest at the ankle and gradually less towards the knee and thigh.

The bandages are reapplied every week or so. It is best to put the bandages on after you have elevated the leg for several hours or overnight .So, make extra effort to keep your leg elevated just before the nurse is due to see you.

A note of caution: when you have a compression bandage on you should still be able to move your ankle around. Occasionally, the compression is too tight, or it may affect the circulation in the legs. Therefore, take off the bandages if your foot changes colour or temperature, or if you have increasing pain. Then see your doctor or nurse for advice.

  • Elevations while resting are important if your leg is swollen. The aim is to let gravity help to pull fluid and blood in the right direction - towards the heart. This reduces swelling in the leg and reduces the pressure of blood in the leg veins. However, do not spend all your time in bed or resting, and keep as active as you can and do normal activities. If possible, regular walks are good but do not stand still for long periods.
  • Other treatments in some peopleinclude treating anemia, poor nutrition, swelling of the legs and other medical problems may mean that the skin has less chance of healing well. Other treatments may be needed to help heal a venous leg ulcer. For example:
    • Try to stop smoking if you are a smoker.
    • Antibiotics are sometimes advised for short periods if the skin and tissues around the ulcer become infected.
    • Painkillers if the ulcer is painful.
    • Skin care by a doctor or nurse is advised.
    • Dietary advice if your diet is not very good. Also, if you are overweight then losing some weight may help. Obesity is a risk factor for developing venous leg ulcers.
    • Iron tablets or other treatments if you are anaemic.
    • Pentoxifylline is a drug which improves blood circulation and you may be offered this drug to promote healing of the ulcer.
    • A skin graft may be advised for a large ulcer, or for one that does not heal well.
    • Surgery for varicose veins or other vein problems is advised in some cases. This may correct back pressure of blood pooling in the veins and allow an ulcer to heal.

What is the outlook?

Up to 7 in 10 venous ulcers heal within 12 weeks if treated with compression bandaging which is reapplied every week or so. If compression is not used and an ordinary dressing or compression stockings alone are used, the chance of healing is less.

How do you prevent venous ulcers?

Venous leg ulcers commonly recur (come back) after they have healed. To prevent this, your should wear a compression stocking during the daytime for at least five years after the ulcer has healed. This counteracts the raised pressure in the veins that causes venous leg ulcers.

There are different classes (strengths) of compression stockings - class 1, 2 and 3. The higher the class (class 3) the greater the compression. Ideally, wear class 3 stockings. However, some people find class 3 stockings too tight and uncomfortable but class 2 may be fine.

Sometimes surgery for varicose veins or other vein problems is advised after an ulcer has healed, in order to help prevent a recurrence

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