Overview

A leg ulcer is a long-lasting (chronic) sore that takes more than 2 weeks to heal. They usually develop on the inside of the leg, just above the ankle.

The symptoms of a venous leg ulcer include pain, itching and swelling in the affected leg.

There may also be discoloured or hardened skin around the ulcer, and the sore may produce a foul-smelling discharge.

See your GP if you think you have a leg ulcer, as it will need specialist treatment to help it heal.

Your GP will examine your leg and may carry out additional tests to rule out other conditions.

What causes venous leg ulcers?

A venous leg ulcer is the most common type of leg ulcer, accounting for more than 60% of all cases.

Venous leg ulcers can develop after a minor injury, where persistently high pressure in the veins of the legs has damaged the skin.

Who's affected?

Venous leg ulcers are estimated to affect around 1 in 500 people in the UK, although they become much more common with age.

It's estimated that around 1 in 50 people over the age of 80 has one.

You're more at risk of developing one if you've previously had deep vein thrombosis (DVT) or find it difficult to walk because of a problem such as:

• osteoarthritis,
• a leg injury
• obesity
• paralysis

You're also more at risk if you've recently had an operation on your leg, such as a hip replacement or knee replacement

People with have varicose veins (swollen and enlarged veins) also have a higher risk of developing venous leg ulcers.

How venous leg ulcers are treated

Most venous leg ulcers heal within 6 months if they're treated by a healthcare professional trained in compression therapy for leg ulcers. 

But some ulcers may take longer to heal, and a very small number never heal.

Treatment usually involves:

• cleaning and dressing the wound
• using compression, such as bandages or stockings, to improve the flow of blood in the legs

Antibiotics may also be used if the ulcer becomes infected, but they do not help ulcers heal.

But unless the underlying cause of the ulcer is addressed, there's a high risk of a venous leg ulcer recurring after treatment.

Underlying causes could include immobility, obesity, previous DVT, or varicose veins.

Can venous leg ulcers be prevented?

There are several ways to help prevent developing a venous leg ulcer in people at risk.

These include:

• wearing compression stockings
• losing weight if you're overweight
• exercising regularly
• elevating your leg when possible
• stopping smoking if you smoke

These measures are particularly important if you previously had a leg ulcer. 

This is because you're at increased risk of having another one in the same leg within months or years.

Other types of leg ulcer

Other common types of leg ulcer include:

• arterial leg ulcers - caused by poor blood circulation in the arteries
• diabetic leg ulcers - caused by the high blood sugar associated with diabetes
• vasculitic leg ulcers - associated with chronic inflammatory disorders such as rheumatoid arthritis and lupus
• traumatic leg ulcers - caused by injury to the leg
• malignant leg ulcers - caused by a tumour of the skin of the leg

Most ulcers caused by artery disease or diabetes occur on the foot rather than the leg.

Symptoms

Venous leg ulcers are open, often painful, sores in the skin that take more than 2 weeks to heal. They usually develop on the inside of the leg, just above the ankle.

If you have a venous leg ulcer, you may also have:

• swollen ankles (oedema)
• discolouration and darkening of your skin around the ulcer
• hardened skin around the ulcer, which may make your leg feel hard 
• a heavy feeling in your legs
• aching or swelling in your legs
• flaky, scaly and itchy skin on your legs (varicose eczema)
• swollen and enlarged veins on your legs (varicose veins)

Signs of an infection

A venous leg ulcer can be susceptible to bacterial infection.

Symptoms of an infected leg ulcer can include:

• worsening pain
• a green or unpleasant discharge coming from the ulcer
• redness and swelling of the skin around the ulcer
• a high temperature (fever)
• an unpleasant smell coming from the ulcer

When to seek medical advice

Contact your GP if you think you've developed a venous leg ulcer. They're unlikely to get better on their own, as they usually require specialist medical treatment.

You should also contact your GP or leg ulcer specialist if you've been diagnosed with a venous leg ulcer and have symptoms that suggest it could be infected.

Who can get it

A venous leg ulcer can develop after a minor injury if there's a problem with the circulation of blood in your leg veins. If this happens, pressure inside the veins increases.

This constant high pressure can gradually damage the tiny blood vessels in your skin and make it fragile.

As a result, your skin can easily break and form an ulcer after a knock or scratch.

Unless you have treatment to improve the circulation in your legs, the ulcer may not heal.

Who's most at risk?

A number of factors can increase your risk of developing a venous leg ulcer, including:

• obesity or being overweight - this increases the pressure in the leg veins
• if you have difficulty walking - this can weaken the calf muscles, which can affect circulation in the leg veins
• previous deep vein thrombosis (DVT) - blood clots that develop in the leg can damage valves in the veins
• varicose veins - swollen and enlarged veins caused by malfunctioning valves
• a previous injury to the leg, such as a broken or fractured bone, which may cause DVT or impair walking
• previous surgery to the leg, such as a hip replacement or knee replacement, which can prevent you from moving about
• increasing age - people find it harder to move around as they get older, particularly if they suffer from arthritis

Diagnosis

See your GP if you think you have a venous leg ulcer. The ulcer is unlikely to heal without specialist treatment.

Diagnosis is largely based on your symptoms and examination of your affected leg, although additional tests may be required.

Medical history and examination

Your GP or practice nurse will ask whether you have any other symptoms associated with venous leg ulcers, such as:

• swelling in your ankles
• discoloured or hard skin

They'll try to determine the cause of the ulcer by asking about underlying conditions or previous injuries, such as:

• diabetes
• deep vein thrombosis
• injury or surgery in the affected leg
• a previous leg ulcer

They'll also examine your leg, both when you're standing up and lying down. 

Varicose veins will be more obvious when you're standing up, and it will be easier to look at the ulcer when you're lying down.

They'll also feel your pulse at your ankles to make sure the arteries in your leg are working properly.

Doppler study

To rule out peripheral arterial disease (a condition affecting the arteries) as a possible cause of your symptoms, your GP or nurse will carry out a test known as a Doppler study.

This involves measuring the blood pressure in the arteries at your ankles and comparing it to the pressure in your arms. 

If you have peripheral arterial disease, the blood pressure in your ankles will be lower than your arms.

It's important to carry out this check, as the main treatment for venous ulcers is compression bandages or stockings to improve the vein circulation in your legs.

It's not safe to apply compression if the ankle artery pressures are low.

Referral to a specialist

In some cases, your GP or nurse may decide to refer you to a specialist in conditions affecting the blood vessels (vascular specialist).

For example, you may be referred to a vascular specialist if your GP or nurse is unsure about your diagnosis, or if they suspect your ulcer may be caused by artery diseases, diabetes or rheumatoid arthritis.

After taking your medical history and examining you, the vascular specialist may need to arrange further investigations to plan your treatment.

Treatment

With appropriate treatment, most venous leg ulcers heal within 3 to 4  months.

Treatment should always be carried out by a healthcare professional trained in compression therapy for leg ulcers. This will usually be a practice or district nurse.

Cleaning and dressing the ulcer

The first step is to remove any debris or dead tissue from the ulcer and apply an appropriate dressing. This provides the best conditions for the ulcer to heal.

A simple, non-sticky dressing will be used to dress your ulcer. This usually needs to be changed 1 to 3 times a week.

Many people find they can manage cleaning and dressing their own ulcer under the supervision of a nurse.

Compression

To improve vein circulation in your legs and treat swelling, your nurse will apply a firm compression bandage over the affected leg.

These bandages are designed to squeeze your legs and encourage blood to flow upwards towards your heart.

There are many different types of bandage or elastic stockings used to treat venous leg ulcers, which may be made in 2, 3 or 4 different layers.

The application of a compression bandage is a skilled procedure and should only be applied by trained healthcare staff.

The bandage is changed 1 to 3 times a week, when the dressing is changed.

When compression bandages are first applied to an unhealthy ulcer, it's usually painful. 

Ideally, you should have paracetamol or an alternative painkiller prescribed by your GP. 

The pain will lessen once the ulcer starts to heal.

It's important to wear your compression bandage exactly as instructed. If you have any problems, it's usually best to contact your nurse instead of trying to remove it yourself.

If the compression bandage feels a little too tight and is uncomfortable in bed at night, getting up for a short walk will usually help.

But you'll need to remove or cut the bandage off if:

• you get numbness or tingling in your feet or toes
• you get unusual pain in your legs, feet or toes
• your toes become swollen, or look pale or blue

Once you remove the bandage, make sure you keep your leg highly elevated and contact your doctor or nurse as soon as possible.

In some clinics, specialist teams are using new alternatives to compression bandages, such as special stockings or other compressive devices.

These may not be available in every clinic, but it could change the way ulcers are treated in the future.

Your specialist will be able to advise you whether a different approach may help you.

Treating associated symptoms

Swelling in the legs and ankles

Venous leg ulcers are often accompanied by swelling of your feet and ankles (oedema), which is caused by fluid. This can be controlled by compression bandages.

Keeping your leg elevated whenever possible, ideally with your toes above your hips, will also help ease swelling.

You should put a suitcase, sofa cushion or foam wedge under the bottom of your mattress, to help keep your legs raised while you sleep.

You should also keep as active as possible and aim to continue with your normal activities.

Regular exercise, such as a daily walk, will help reduce leg swelling.

But you should avoid sitting or standing still with your feet down. You should elevate your feet for 30 minutes, 3 to 4 times a day.

Itchy skin 

Some people with venous leg ulcers develop rashes with scaly and itchy skin.

This is often caused by varicose eczema, which can be treated with a moisturiser (emollient) and occasionally a mild corticosteroid cream or ointment.

In rare cases, you may need to be referred to a dermatologist (skin specialist) for treatment.

Itchy skin can also sometimes be caused by an allergic reaction to the dressings or creams applied by your nurse. If this happens, you may need to be tested for allergies.

It's important to avoid scratching your legs if they feel itchy as this damages the skin and may lead to further ulcers.

Looking after yourself during treatment

The following advice may help your ulcer heal more quickly.

• Try to keep active by walking regularly. Sitting and standing still without elevating your legs can make venous leg ulcers and swelling worse.
• Whenever you're sitting or lying down, keep your affected leg elevated.
• Regularly exercise your legs by moving your feet up and down, and rotating them at the ankles. This can help encourage better circulation.
• If you're overweight, try to reduce your weight with a healthy diet and regular exercise.
• Stop smoking and moderate your alcohol consumption. This can help the ulcer heal faster.
• Be careful not to injure your affected leg, and wear comfortable, well-fitting footwear.

Treating an infected ulcer

An ulcer sometimes produces a large amount of discharge and becomes more painful. There may also be redness around the ulcer. However redness may be harder to see on black or brown skin.

These symptoms and feeling unwell are signs of infection. You should contact your GP or leg ulcer specialist as soon as possible.

If your ulcer becomes infected, it should be cleaned and dressed as usual.

You should also elevate your leg most of the time. You'll be prescribed a seven-day course of antibiotics.

The aim of antibiotic treatment is to clear the infection. But antibiotics do not heal ulcers and should only be used in short courses to treat infected ulcers.

Follow-up

You should visit your nurse once a week to have your dressings and compression bandages changed. They'll also monitor the ulcer to see how well it's healing.

Once your ulcer is healing well, your nurse will see you less often.

After your leg ulcer has healed

Once you've had a venous leg ulcer, another ulcer could develop within months or years.

The most effective method of preventing this is to wear compression stockings at all times when you're out of bed.

Your nurse will help you find a stocking that fits correctly and you can manage yourself.

Various accessories are available to help you put them on and take them off.

Prevention

You can help reduce your risk of developing a venous leg ulcer in several ways, such as wearing a compression stocking, losing weight and taking care of your skin.

People most at risk of developing a venous leg ulcer are those who have previously had a leg ulcer.

Compression stockings

If you had a venous leg ulcer before or you're at risk of developing one, treatment with compression stockings may be recommended by your GP.

These stockings are specially designed to squeeze your legs, improving your circulation.

They're usually tightest at the ankle and less tight further up your leg. This encourages blood to flow upwards towards your heart.

To be most effective, these stockings should be put on as you get up and only taken off at night.

Compression stockings are available in a variety of different sizes, colours, styles and pressures.

A nurse can help you find a stocking that fits correctly and you can manage yourself. There are various accessories you can buy to help get the stockings on and off.

Losing weight

If you're obese or overweight, losing weight can help treat and prevent venous leg ulcers.

Excess weight leads to high pressure in the veins in your legs, which can damage your skin.

Venous ulcers are much more common among people who are overweight.

To help you lose weight, regular exercise and a healthy, balanced diet are recommended.

You should also avoid sitting or standing for long periods. Elevating your legs whenever possible can also help.

Treating underlying problems

Treating severe varicose veins may help prevent leg swelling or ulcers.

This may involve a procedure where a thin, flexible tube called a catheter is inserted into the affected veins, with high-frequency radio waves or lasers used to seal them.

Alternatively, you may need surgery to repair the damage to your leg veins or remove the affected veins altogether.