Leg Ulcers

Summary for patients:

A leg ulcer is where an area of skin has broken down and you can see the underlying flesh. They’re common in older people and women suffer more than men. Without treatment, they can get bigger and cause problems in the affected leg. Compression bandages and hosiery are used to treat ulcers as they counteract the raised pressure in the leg veins and allow the ulcer to heal. It helps if you can elevate the affected leg just before the compression is applied.

Suitable Products for Treatment and Prevention for Leg Ulcers

 

 

 

For health practitioners:

A leg ulcer is defined as “an open lesion between the knee and the ankle joint that remains unhealed for at least four weeks and occurs in the presence of venous disease”.¹ Chronic venous ulceration has a prevalence between 0.1% and 0.3% in the UK with approximately 1% of the population suffering from leg ulceration at some point in their lives.² 85% are treated by Primary Healthcare teams at an annual cost of £3 – £600 million with the greatest percentage of cost being nursing time.³

Chronic Venous Insufficiency (CVI)

Chronic Venous Insufficiency (CVI) is characterised by poor venous return and venous reflux due to incompetent valves in the veins leading to an increase in venous pressure (venous hypertension).  There are 7 stages of CVI⁴ based on the severity of the clinical signs present, from “heavy legs” (C0) through varicose veins (C2) and Venous Oedema (C3) to the final stage of Active Venous Ulceration (C6).

Chronic venous leg ulcers are associated with high levels of morbidity and a dramatic reduction in quality of life⁵

Venous leg ulcers

Venous leg ulcers account for 70 – 75% of all leg ulcers seen and have specific characteristics differentiating them from arterial leg ulcers which affect 10 – 15% of patients with leg ulceration (see table 1).

The increased pressure in the veins, due to venous reflux, causes proteins from the broken down haemoglobin to leak into the tissues resulting in brown staining of the skin, usually in the gaiter area. The tissues become hard and woody (Lipodermatoschlerosis) and Varicose Eczema can develop which contributes to the development of an ulcer.

Table 1. Signs and symptoms of arterial and venous leg ulcers

	Arterial / Ischaemic Ulcers	Venous Ulcers
Cause	Arterial disease / Diabetes	Chronic venous hypertension
Wound bedappearance	Deep ‘Cliff edge’ margins	Shallow Irregular wound margins
Evolution	Rapid progression	Insidious onset / Slow evolution
Skin aspect	Shiny Pale/dusky Cold to touch Hair loss Lack of nail growth	Pigmented Eczema Warm to touch Ankle flare Atrophie Blanche
Foot pulses	Absent or diminished	Present
Location	At the extremities: foot and toes	Lateral or medial malleolus / Gaiter region
Oedema	Dependent or localised oedema	Generalised oedema which worsens during the day
Pain	Severe ischaemic pain /Pain on exercise	Generalised nagging pain, which becomes worse if infected
Doppler reading	< 0.5	> 0.8
Associated past medical history	Hypertension/Ischaemic heart disease / TIA / RA / CVA /Peripheral Vascular Disease	Varicose veins / DVT / Thrombophlebitis / DVT & Post-thrombotic syndrome/Multiple pregnancies

Graduated compression therapy, either bandages or hosiery, is the clinically proven, recommended treatment for venous leg ulcers with 40mmHg applied at the ankle.⁷ Arterial leg ulcers are treated more conservatively dependent on the level of arterial involvement and revascularisation may be attempted prior to treatment for the leg ulcer.⁸

References

1. SIGN Guideline 120
2. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Chronic ulcer of the leg: clinical history. Br Med J (Clin Res Ed) 1987;294(6584):1389-91.
3. Iglesias CP, Nelson EA, Cullum N, Torgerson DJ., VenUS I collaborators Economic analysis of VenUS I, a randomized trial of two bandages for treating venous leg ulcers. Br J Surg. 2004;91(10):1300–1306
4. CEAP International Classification
5. Callam. Prevalence of chronic leg ulceration and severe chronic venous disease in western countries. Phlebology 1992;7(Suppl 1):6-12.
6. Persoon A, Heinen MM, van der Vleuten CJ, de Rooij MJ, van de Kerkhof PC, van Achterberg T. Leg ulcers: a review of their impact on daily life. J Clin Nurs 2004;13(3):341-54.
7. EWMA positioning document 2003
8. Siegreen M (2004) Arterial insufficiency and ulceration diagnosis and treatment options. Nurse Practitioner 9(29): 46-51