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.

🧾 Clinical Case Examples – Venous Insufficiency & Leg Ulcers

Case 1 – Classic Venous Ulcer 🦵 A 72-year-old woman with varicose veins presents with a shallow, exudative ulcer above the medial malleolus. The surrounding skin shows haemosiderin pigmentation, lipodermatosclerosis, and oedema. 👉 Managed with compression bandaging, emollients, and vascular referral.

Case 2 – Recurrent Ulcer with Infection 🦠 A 65-year-old man with chronic venous insufficiency develops a painful, weeping ulcer with surrounding cellulitis. He reports longstanding leg swelling worsened by standing. 👉 Treated with compression therapy, oral antibiotics, leg elevation, and wound care.

Case 3 – Post-DVT Syndrome 🩸 A 58-year-old woman with a history of DVT 5 years ago presents with a non-healing ulcer and severe oedema in the left lower leg. Doppler shows venous reflux. 👉 Diagnosis: Post-thrombotic venous ulcer. Managed with multilayer compression, physiotherapy, and anticoagulation review.

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Venous Insufficiency and Leg Ulcers