Makindo Medical Notes

Venous leg ulcers are a chronic, recurring condition. Always assess foot pulses and calculate the Ankle Brachial Pressure Index (ABPI) 🦶 to determine suitability for compression therapy.

📖 About

• Venous ulcers are the most common type of ulcer affecting the lower extremities.
• They account for up to 70% of chronic leg ulcers in the UK.

🧬 Aetiology

• Secondary to venous stasis from valve incompetence or venous obstruction.
• Venous hypertension → chronic venous distension → thinning of skin & breakdown.
• May follow minor trauma to the leg.
• Underlying problem: failure of calf-muscle pump + damaged valves → impaired venous return.

⚠️ Risk Factors

• Increasing age 👵
• Previous DVT or thrombophlebitis
• Obesity ⚖️
• Lower limb fracture, surgery, or injury
• Prolonged immobility or standing upright
• Hypertension
• Multiple pregnancies 🤰
• Varicose veins
• Corticosteroid use (delays healing)
• Nicorandil has been associated with ulcer formation.

🩺 Clinical Features

• Chronic, shallow, full-thickness ulcers over the gaiter region (medial lower leg above the ankle).
• Often exudative with irregular margins.
• Associated features:
  • Brownish skin discolouration (haemosiderin staining).
  • Venous eczema / dermatitis.
  • Lipodermatosclerosis (indurated, tight “inverted champagne bottle” leg).
  • Thickened toenails.

🔍 Differentials

• Arterial ulcer (punched-out, painful, distal sites, low ABPI).
• Neuropathic ulcer (diabetes, pressure points).
• Pyoderma gangrenosum (painful, undermined edges).
• Traumatic ulcer.

🧪 Investigations

• Bloods: FBC, U&E, ESR/CRP (infection), albumin (nutrition), HbA1c (diabetes).
• Doppler ultrasound + ABPI:
  • ABPI 0.8–1.3 → compression safe ✅
  • ABPI <0.8 → avoid full compression ❌ (arterial disease risk)
• Duplex USS → valve incompetence/venous obstruction.
• Swabs ONLY if clinical infection (erythema, purulent discharge, systemic signs).

💊 Management

• 🎯 General measures:
  • Treat oedema, control infection.
  • Leg elevation (above heart level).
  • Weight reduction and mobility encouragement.
• 🧴 Wound care:
  • Regular cleansing and moist wound dressings.
  • Debridement to remove slough/necrotic tissue.
• 🧦 Compression therapy:
  • Gold standard: four-layer compression bandage.
  • Improves healing, reduces recurrence, relieves symptoms.
  • ⚠️ Contraindicated if arterial insufficiency (ABPI <0.8).
• 🩹 Advanced options:
  • Skin grafting for large, stable, non-healing ulcers.
  • Topical agents (e.g. silver dressings) if infected.
• 👩‍⚕️ Specialist referral: vascular surgery for persistent/recurrent ulcers, venous ablation procedures if indicated.

📚 References

• DermNet NZ – Venous Ulcers
• NICE CG168: Varicose Veins in the Legs.
• Oxford Handbook of Clinical Medicine.