Leg ulcers are a chronic condition, the treatment of which has been estimated to cost the NHS between £300 and £600m per year.
Leg Ulcers – Understanding, Treating and Preventing
A leg ulcer is a wound on the lower leg or foot that does not heal within two weeks. Most are venous leg ulcers, caused by problems with the veins that slow blood flow and delay healing. They can be painful, affect mobility, and have a major impact on quality of life — but with the right care, most will heal.
Why They Happen
At least 70% of ulcers are caused by venous disease. About 20%, are caused by some form of arterial disease. Depending upon the location and severity of the problem, this may affect large parts of the leg or smaller localised areas of tissue. The prevalence of ischaemic or arterial ulcers also rises with increasing age. Other important causes of ulceration include diabetes and trauma to the skin around the lower leg especially in elderly people where the skin is extremely thin and heals very poorly. Ulcers that are caused by arterial disease or show no signs of healing despite adequate measures should be referred to a specialist vascular surgeon for assessment and possible surgery.
What sort of ulcer have I got?
It would not be a good idea for you to guess the type of ulcer you may have. Studies have shown that even doctors cannot tell the cause of an ulcer just by looking at it carefully. You should be referred to a vascular specialist to have a full assessment of your medical history followed by an examination of your ulcer and circulation.
Your consultant may request some special tests to examine your circulation in more detail, most commonly an ultrasound test of your veins and arteries (duplex scan). If your ulcer is due to arterial disease, an angiogram may be necessary.
Anatomy of the venous system
Arteries are the pipes that take blood into your leg. This then has to be returned to the heart by the veins. There are 2 systems of veins in your leg. The veins you can see just under your skin are called the superficial veins. There is another set of deeper veins that are located within the muscle and adjacent to the bones of your leg. All these veins contain one-way valves so that the blood can only flow in one direction towards the heart-this is helped by the contraction of your calf muscles (called the calf muscle pump). The deep veins communicate with the superficial veins via a system of short bridging veins called perforating veins.
Venous ulceration
Blockage or damage to the venous system will cause disruption to normal blood flow, which may manifest itself in a number of different ways. If the valves in the superficial system are affected, venous return will be impaired and blood may accumulate in the veins causing them to become distended and varicose.
Following a deep vein thrombosis, the resulting damage to the deep veins may cause a complete or partial obstruction. Blood will begin to collect within the deep veins eventually being forced out into the superficial veins due to the unrelieved pressure produced by the calf muscle pump. The extra pressure in the superficial veins may cause them to become varicose and blood cells to leak out into the skin. The red pigment (haemoglobin) contained within blood cells, causes a brownish staining of the skin around the ankle- an early indicator of possible ulcer formation. At this stage, any trauma from a small knock or scratch may result in skin breakdown and ulcer formation. If not dealt with quickly, this will progress with the end result of a large, malodorous and painful ulcer.
Modern Management
The goals are to heal the ulcer, treat the underlying cause, and prevent recurrence. This usually involves:
*Compression therapy; specialist bandages or stockings to improve blood flow and reduce swelling.
*Wound care – gentle cleaning and dressings to protect the skin and encourage healing.
*Treating the underlying vein problem, often with minimally invasive procedures such as endovenous ablation, which closes the faulty veins and restores healthier circulation.
Evidence That Shapes Best Practice
EVRA Trial (2018)
showed that early treatment of the underlying vein problem, alongside compression, significantly speeds up healing and reduces the risk of ulcers returning. This challenged the old approach of waiting until the ulcer had healed before treating the veins.SIGN Guidelines
recommend early referral to a vascular specialist, duplex ultrasound to confirm the diagnosis, and, where suitable, early endovenous treatment in addition to compression.Recovery and Reducing the Risk of Recurrence
Even after healing, the underlying vein problem may remain. To reduce the risk of another ulcer:
*Wear compression stockings as advised.
*Keep active and walk regularly.
*Elevate your legs when resting.
*Maintain a healthy weight and balanced diet.
*Seek specialist advice promptly if you notice skin changes, swelling, or discomfort.