What is a leg ulcer?
A leg ulcer is simply a break in the skin of the leg, which allows air and bacteria to get into the underlying tissue. This is usually caused by an injury, often a minor one that breaks the skin.
In most people, such an injury will heal up without difficulty within a week or two. However, when there is an underlying problem the skin does not heal and the area of breakdown can increase in size. This is a chronic leg ulcer.
What causes leg ulcers?
The most common underlying problem causing chronic leg ulcers is a disease of the veins of the leg. Venous disease is the main reason for over two-thirds of all leg ulcers.
- Venous Disease (caused by veins not working) – about 80% of leg ulcers
- Arterial Disease (caused by the arteries not working) – about 15% of leg ulcers
- Other causes (includes diabetes and rheumatoid arthritis as well as some rare conditions) – about 5% of leg ulcers
In some cases, two or more conditions may be causing damage at the same time. Your doctor will examine you and do some tests to see what sort of ulcer you have. The following advice applies to venous ulcers and may not be appropriate for other sorts of ulcers.
How does venous disease cause ulcers?
The veins in your leg are tubes that carry the blood back from the foot towards your heart. The veins in your legs have one-way valves that make sure the blood flows up the leg and not back down. In some people, these valves are not very effective or can be damaged by thrombosis (clots) in the veins. If the valves are damaged, blood can flow the wrong way down the veins, which results in very high pressure in the veins when standing up. This abnormally high pressure in the veins damages the skin and leads to ulcers.
How will I be treated?
Treatment of a venous leg ulcer happens in two ways:
- Controlling the high pressure in the leg veins
- Treatment of the ulcer
The mainstays of treatment are
- compression bandaging or
- stockings and
- elevation of the limb
- Treatment of reflux
- Treatment of deep veins
Elevation of the limb
The higher the leg, the lower the pressure in the leg veins. If the foot is elevated above the heart then the pressure in the foot drops to a normal level. Put your legs up whenever you can and as high as you are able-the arm of the sofa is good.
Compression bandaging or stocking
In order to keep the pressure in the leg veins at the ankle low when you are standing up, you will be treated with compression bandaging or stockings. Several layers of bandages may be required to get the necessary pressure to control the veins. Once the ulcer is healed, compression stockings are usually necessary to prevent the ulcer from returning. These stockings need to be specially fitted and are much stronger than ordinary “support tights”. If you have difficulty putting on your stockings then you can buy a special stocking applicator.
Dressings
The nurse will use a number of different dressings under the bandages depending on the state of the ulcer itself. These dressings may well change as the ulcer progresses.
Surgery
This is indicated for a patient with
- Superficial venous reflux – this is treated by sealing the leaking vein by laser / RFA procedure
- Deep venous occlusion – this will require angiogram with angioplasty/stenting of the veins
How long will it take for the ulcer to heal?
It has usually taken many years for the venous disease to cause the ulcers, so it is not surprising that the ulcers may take a fairly long time to heal. Although most venous ulcers will heal in 3-4 months, a small proportion will take considerably longer. Don’t despair! Even in these resistant cases, treatment is eventually successful.
How can I stop the ulcer from coming back?
Once your ulcer is healed, it does not mean that your problems are over. Your skin damage remains and you must take precautions to prevent the ulcer from recurring:
- Wear compression stockings (or bandages in a few severe cases) at all times during the day.
- Elevate the legs whenever possible.
- Keep the skin in good condition by using plenty of moisturising cream to prevent dryness.
- Weight loss, fresh fruit, exercise and stopping smoking are also vital to help heal your ulcer as well as for your general health.
Severe Venous Leg Ulcers Treated
International Publications on Venous Disease Management
- Contralateral deep-vein thrombosis in lliac vein stenting – Incidence, etiology, and prevention. Indian J VascEndovascSurg 2021;8, Suppl S1:11-7.DOI: 10.4103/ijves.ijves_54_21
- Effect of deep vein stenting on healing of lower limb venous ulcers. European Journal of Vascular Surgery doi: 10.1016/j.ejvs.2014.04.031
- Experience of on table modified standard catheters for directed arterial and venous thrombolysis. Journal of Thrombosis & Thrombolysis (2016) 42: 56.
https://doi.org/10.1007/s11239-015-1324-1
- Reduction Internal Valvuloplasty (RIVAL) is a New Technical Improvement on Plication Internal Valvuloplasty for Primary Deep Vein Valvular Incompetence. Journal of Vascular Surgery
- Endovascular management of venous ulcer in a patient with occluded duplicated IVC & review of IVC development. Vasc Endovascular Surg. 2014 Feb;48(2):162-5. doi: 10.1177/1538574413510627. Epub 2013 Nov 12.
International Lectures on Venous Disease
- Deep vein Endovenectomy-tips and tricks. International Union of Phlebology. Istanul, Turkey 2022
- Complex venous interventions: Endovascular Asia, Osaka, Japan. Dec 2019
- Assessing deep venous disease with non invasive imaging- Veins International .Meeting, London, UK March 2018
- Hybrid procedures for venous disease- Veins International Meeting, London, UK
- CVI in the obese – reflux or functional obstruction. ASVS , Singapore Oct 2016
Endovenectomy with iliac vein stenting- rationale and technique. ASVS, Singapore
- Oct 2016
Management of deep venous occlusive disease. Asian Society of Vascular Surgery
- Annual Conference, Hong Kong Sep 2014
Diagnosis and treatment of deep venous obstructive lesions. Asia Pacific Vascular
- Symposium. Singapore May 2014
Endovascular recanalization of iliac veins: going beyond standard therapies of
compression and varicose vein surgery. Vascular Society of Great Britain and
- Ireland. Manchester. Nov 2012
