Patients with venous leg ulcers

Around two-thirds of wounds treated by the NHS are on the lower leg. (1) BMJ Journal

Any wounds, lacerations or surgical incision will heal more slowly on the lower limb than other sites, especially in the presence of swelling. Thus it is essential that a leg wound is treated early and any delay in healing or deterioration is swiftly dealt with.

All lower limb wounds will heal faster with the early intervention of compression socks or bandaging, except limbs with critical ischemia. It is essential that the cause of the slow healing or deterioration is understood so that a treatment plan can be developed that is effective so that your care is also effective.

Where there is no identifiable aetiology causing deterioration, treat as a venous ulcer.

Causes of ulcers, sores and knocks on the leg that are not healing

There are a number of reasons why wounds on the lower leg are more likely to have delayed healing:

The most common cause of poor healing in the lower legs is venous hypertension.

What do leg ulcers look like?

a image of venous leg ulcers or sore, after knock - Legs Matter
Leg ulcers are sores that can develop between your knee and ankle. They often begin as shallow ulcers with uneven edges that drain or weep a lot.

Assessment of a patient with a possible venous leg ulcer

You should give everyone who presents with a wound on the lower leg that has failed to heal within 2 weeks a comprehensive assessment. This should include a detailed wound assessment.

Your assessment should include:

  • A general assessment that views the patient holistically, taking into consideration lifestyle, overall health problems, including underlying causes for ulceration or relevant medical history
    Wounds UK – Best Practice Statement, Holistic Management of Venous Leg Ulceration (PDF Download – Open access – registration required to download)
  • Possible risk factors for venous hypertension and arterial disease
    Wounds UK – Best Practice Statement, Holistic Management of Venous Leg Ulceration (PDF Download – Open access – registration required to download)
  • Doppler ultrasound to record an Ankle Brachial Pressure Index (ABPI). This test screens for clinically significant arterial impairment. ABPI assessments should be completed at 3, 6 or twelve-month intervals, depending on initial and ongoing assessment outcomes, cardiovascular risk profile, patient needs, or according to local guidelines.
    NICE, 2013 (Web page)
    World Wide Wounds (Web page)

If your patient appears to have problems with their veins or arteries, you should refer them for further vascular tests.

There are some rare but destructive causes of ulceration. You should refer your patient for urgent advice and diagnosis if they have:

  • A rapidly deteriorating wound (increasing size or tissue necrosis)
  • Significant pain that cannot be relieved

Treatment for venous leg ulcers

Venous hypertension (venous leg ulcers)

  • The first line treatment for venous hypertension is compression therapy
  • Aim for high compression therapy for more rapid healing
  • The compression modality (the product chosen) should be acceptable to the patient’s needs. Hosiery kits and compression wraps may be an alternative option to bandages
  • Compression therapy can initially be uncomfortable so it is important to address pain with appropriate analgesia
  • Dressings should be low adherent
  • Oral pentoxifylline improves healing
  • Do not use reduced compression unless ABPI is less than 0.8
  • If the exudate needs daily or 3 changes weekly, then the level of compression may be inadequate or inconsistently applied. Review efficacy and technique used
  • Remember that reduced compression therapy will be inadequate for the majority of leg ulcers, especially in the presence of oedema

There is no evidence that any particular form of cleansing, debridement or dressing is particularly beneficial.

All patients with venous ulceration or suspected venous ulceration should have assessment of their veins by the means of venous duplex scans or Magnetic Resonance Venogram (MRV), to determine whether there is evidence of venous insufficiency. If it is possible to correct surgically, this will improve healing times and reduce the risk of recurrence (Gohel 2018).

Additional resources:

NICE (Web page)

Arterial insufficiency

Surgery – Surgery may be beneficial for patients with troublesome symptoms.  You should consider referring them to a vascular service

Painkillers – Make sure you assess pain and give advice on appropriate analgesia.

Smoking – Encourage your patients to stop smoking.

Do not offer compression therapy to people with significant arterial impairment

Other conditions which may slow wound healing

Conditions which may delay healing in the lower leg can include:

  • Inflammatory disease (such as rheumatoid arthritis, systemic lupus erythematosus)
  • Vasculitis
  • Pyoderma gangrenosum
  • Raynaud’s disease
  • Haematological disease
  • Infection (such as TB, tropical infection)
  • Lymphoedema
  • Recurrent trauma
  • Skin cancer
  • Sickle cell disease

Medications that may inhibit healing:

  • Amlodopine

Medication that can cause ulceration:

  • Hydroxyurea
  • Nicorandil

If you suspect these causes, you should refer your patient to an appropriate specialist.

When to refer for assistance:

  • When management consistently requires 3 or more dressings per week; the compression regime is likely to be inadequate for the patient
  • When severe pain is preventing the use of high compression therapy
  • When, despite standard management, the wound is failing to heal in 8 weeks

Publications & Evidence for venous leg ulcers

We’ve carefully curated resources to help in your everyday work.

Read more

Clinical guidelines for venous leg ulcers

These guidelines will give you a useful overview and more detailed information about venous leg ulcer management:

You can find more national and international guidelines for venous leg ulcer management here.

Research surrounding venous leg ulcers

The Cochrane Library publishes systematic reviews about the effectiveness of  many treatments for venous leg ulcers and summarises this in a useful ‘Evidently Cochrane’ paper (Web page).

Patient information for venous leg ulcers

The patients, family and friends section has lots of useful, accessible information for your patients.

Read more

Dowload a patient information leaflet as a pdf to print

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