Lower limb ulcers are a manifestation of underlying vascular, neurological, or pressure-related pathology. Correctly identifying the ulcer type is essential — treatments that help venous ulcers (e.g. compression) can be dangerous in arterial disease.

⚖️ Comparison of Venous vs Arterial Ulcers

🔍 Feature	🟤 Venous Ulcers	🔴 Arterial Ulcers
Typical location	Gaiter area – medial lower leg, above the ankle	Toes, foot margins, heel, lateral malleolus
Appearance	Shallow, irregular edges, moist, exudative	Punched-out, deep, dry, often necrotic
Pain	Mild–moderate; relieved by elevation	Severe; worse at night and with elevation
Surrounding skin	Oedema, brown hyperpigmentation, eczema (lipodermatosclerosis)	Shiny, hairless, cool skin; dependent rubor
Pulses	Usually present (may be hard to feel due to oedema)	Reduced or absent
Capillary refill	Normal	Delayed
Underlying pathology	Venous hypertension, valve failure	Atherosclerosis, arterial occlusion
Key investigations	Doppler US; ABPI to exclude arterial disease	ABPI, duplex ultrasound, CT/MR angiography
Management principles	🧦 Compression therapy (if ABPI ≥0.8) 🩹 Wound dressings ⬆️ Leg elevation 🔧 Treat venous reflux (surgery/endovenous)	🚫 Avoid compression 🩺 Urgent vascular referral 🛠️ Revascularisation (angioplasty/bypass) 🚭 Risk factor modification

🟡 Diabetic Foot Ulcers

Result from peripheral neuropathy, pressure points, and impaired perfusion.
Commonly occur on the plantar surface, metatarsal heads, or heel.
Often painless → delayed presentation.
Management:
- 👟 Offloading (special footwear, total contact cast)
- 🩸 Optimise glycaemic control
- 🩹 Regular debridement and dressings
- 🦠 Treat infection promptly
- 🤝 MDT care (diabetes, podiatry, vascular)

🟣 Pressure Ulcers

Caused by prolonged pressure over bony prominences → tissue ischaemia.
High risk in immobile, frail, or malnourished patients.
Common sites: heels, sacrum, hips.
Management:
- 🔄 Regular repositioning
- 🛏️ Pressure-relieving mattresses
- 🩹 Wound care ± debridement
- 🥗 Nutritional optimisation

⚠️ Red Flags (Any Ulcer Type)

🚨 Increasing pain, spreading erythema, purulent discharge
🦠 Signs of systemic infection or sepsis
⚫ Rapidly enlarging or necrotic ulcer
🩸 Suspected critical limb ischaemia

📚 Key Teaching Pearls

🧠 Ulcer type = underlying pathology — treat the cause, not just the wound.
🧦 Compression helps venous ulcers but can harm arterial ulcers.
🩺 Always check ABPI before compression.
🟡 Diabetic ulcers are often painless — inspect feet routinely.
🤝 Early MDT input reduces amputation risk.

✅ Conclusion

Lower limb ulcers are common but potentially limb-threatening. Accurate classification into venous, arterial, diabetic, or pressure-related ulcers is critical, as management strategies differ fundamentally. Early recognition, appropriate investigation, and targeted treatment significantly improve healing and patient outcomes.

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Venous and Arterial Ulcers and Other Lower Limb Ulcers

🦵 Main Types of Lower Limb Ulcers