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Venous leg ulcers

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What are the aims of this leaflet?

This leaflet has been written to help you understand more about venous leg ulcers.  It will tell you what venous leg ulcers are, what causes them, what can be done about them, and where you can find out more about them.

What is a venous leg ulcer?

A venous leg ulcer is an open sore in the skin of the lower leg due to high pressure of the blood in the leg veins.

What causes venous leg ulcers?

The main cause of venous leg ulcers is faulty valves inside the leg veins. These valves normally allow the blood to flow up the leg towards the heart, and prevent backward flow down the leg. If they are faulty, backward flow is not prevented and pressure builds up inside the veins. The persistent high pressure in the leg veins, caused by the faulty valves, damages tiny blood vessels in the skin. The skin then becomes thin and inflamed, doesn’t heal well, and can easily break down to leave an open sore, otherwise known as an ulcer.

Some people are born with poor valves.  In other people, the valves are damaged after a venous thrombosis (a blood clot forming within a vein).  Valves tend to weaken with age.

Are venous leg ulcers hereditary?

Venous leg ulcers are not hereditary.  However, some of the things that put you at risk of developing a venous leg ulcer do run in families - such as poor valves or a tendency to have a blood clot.

What does a venous ulcer look like and what are its symptoms?

Before the ulcer appears, you may notice your leg swelling and you may find it painful to stand for long periods. Brown spots and patches may appear on the skin, and the altered blood flow can turn the skin various shades lying between red and blue.  Your skin may become irritated or scaly, and firm tender areas may develop under it.

The ulcer itself is an open sore. The bed of the ulcer may show bumpy, moist and red healing tissue, or may be covered in a yellowish-grey mucky-looking layer.  Ulcers often leak fluid - in amounts that vary from a lot to a little.

A venous ulcer can be painful, although the pain is usually relieved when the pressure is controlled by raising the leg or by wearing compression bandages or stockings. Some people find that it is painful to expose their ulcer to the air when the dressing is being changed.  However, if your ulcer gives you severe pain, this may mean that it has other causes, such as blockages in the arteries, and you should tell your doctor.

How will a venous ulcer be diagnosed?

The changes that you see in your skin will suggest to your doctor that you have a venous leg ulcer. However, it is important to check for other possible causes, especially a poor arterial circulation.  To do this, the doctor or nurse will feel for the pulses in your foot and may measure the blood pressure in your leg with a small ultrasound instrument (“Doppler”).  Occasionally other tests are needed, such as removing a small piece of skin for microscopic examination (a biopsy), blood tests, or more specialised investigation of the circulation in an X-ray department.

Can a venous leg ulcer be cured?

If it is simply a venous ulcer, yes.  But if other conditions such as diseased arteries are contributing to the ulcer, it may be more difficult.

How can a venous ulcer be treated?

To start with, a nurse will usually clean your ulcer and the skin surrounding it. Salt water may be used for this.  Sometimes, your entire leg and foot, including the ulcer, will be cleaned with lukewarm tap water and from time to time an emollient (moisturising) oil or an antiseptic may be added to the water. 

A dressing will then be put over the open ulcer. There are many types, but one of the most common is a simple non-stick fabric dressing.  The dressing will be covered by a compression bandage or stocking, from your toes to your knees.  These stop the damaging effects of the high pressure in the veins.  If you are given compression bandages, one example of this is multilayer (or “four-layer”) bandaging.  Alternatively you may be given compression stockings. Usually bandages are used until the ulcer has healed or nearly healed, and then stockings are used after that.

Other treatments for your ulcer might include an emollient (moisturising) cream for dry skin, antibiotics for infection, and a steroid cream for any eczema surrounding the ulcer.  Sometimes the itchy rough skin around an ulcer is due to a contact allergy to something present in the dressings that are being used to treat it, or in the creams and ointments being put on around it.  Lanolin, topical antibiotics, and preservatives are commonly involved in this. If contact allergy is suspected, it may be worth investigating this by testing your skin against the most likely culprits (by patch testing).

If healing is very slow, pinch skin grafting to the ulcer may be considered.  In some cases, an operation on the veins helps to reduce the pressure. 

What can I do to help?

• Compression bandages or stockings work best if you exercise your leg regularly, for example by walking.  If you are less mobile, exercise your leg muscles by moving your foot up and down at the ankle.
• When you are sitting down, keep your legs raised by putting your feet on a stool or a chair.  Don’t sleep in a chair with your legs hanging down and avoid standing up for a long time.
• If you smoke, you should cut down and preferably stop.
• You should have a healthy balanced diet. If you are too heavy, try to lose weight.
• Follow the instructions carefully when you wash your stockings or bandages.  Washing them at the wrong temperatures can damage the elastic.  You need to make sure they are replaced regularly because over time, they lose their stretch.
• If you put on your stockings yourself, avoid turning over the tops.  Don’t pull them too high up your leg.

Where can I get more information?

Websites:

The Prodigy website: www.prodigy-nhs.uk   - look for Visitor Toolbox on the left, click on Patient Information Leaflets, then the letter L, then Leg Ulcers – Venous. 

The website of the American College of Phlebology: www.phlebology.org; select “Topics in Phlebology” from the menu on the left, and choose “Venous leg ulcers: evaluation and management”.

The sources given below are good - but are aimed at a medical audience:

• Phillips TJ. Current approaches to venous ulcers and compression. Dermatologic Surgery 2001; 27: 611-621.
• Simon DA, Dix FP, McCollum CN.  Management of venous leg ulcers.  British Medical Journal 2004; 328: 1358 – 1362.

(While every effort has been made to ensure that the information given in this leaflet is accurate, not every treatment will be suitable or effective for every person. Your own doctor will be able to advise in greater detail)

BAD PATIENT INFORMATION LEAFLET

PRODUCED AUGUST 2004