Patients with leg ulcers, wounds and non-healing sores on the leg

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 therapy, except limbs with significant arterial disease. It is essential that the cause of the wound or the reason for slow healing / deterioration is understood so that a treatment plan can be developed that is effective.

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 occur or have delayed healing these include::

• Venous hypertension – poor venous return from the legs to the heart
• Arterial insufficiency – inadequate blood flow to the legs and feet (usually as a result of atherosclerosis)
• Lymphatic insufficiency – issues with return of fluid within the tissues of the lower limb into the circulatory system
• Other less common diseases such as skin cancers, auto immune disorders, infection, medication, diabetes, haematological disease

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

What do leg ulcers look like?

Venous hypertension / insufficiency

The most common cause of poor healing on the lower leg is venous hypertension. This can also be referred as venous insufficiency, venous reflux or venous disease. In the presence of venous disease the blood can be pushed out into the surrounding tissues. There are 3 main types of blood products:

• Plasma – this results in oedema in the surrounding tissues
• Red blood cells – as these are absorbed into the tissue they leave behind the haemoglobin but results in haemosiderin staining (brown discolouration of the skin)
• White blood cells – these create a chronic inflammatory response which results in local inflammation and ultimately the course of the skin breakdown

To treat patients with venous ulceration successfully you must reduce the venous hypertension.

Assessment of a patient with a leg ulcer

On presentation you should assess the patient for red flags in line with the National Wound Care Strategy lower limb Programme (NWCSP) recommendations (PDF download)

Your assessment should include:

• Acute infection of leg or foot (e.g. increasing unilateral redness, swelling, pain, pus, heat).
• Symptoms of sepsis.
• Acute or chronic limb threatening ischaemia.
• Suspected deep vein thrombosis (DVT).
• Suspected skin cancer.

If there is any indication of red flags then patients should be treated for infection if appropriate and be immediately escalated.

If there are no red flags identified then the patient should be commenced on ‘first line mild graduated compression’ in line with NWCSP recommendations.

In the absence of red flags everyone who presents with a wound on the lower leg should have a full holistic assessment completed within 2 weeks to determine the underlying cause of the wound. This should include a detailed assessment of the patient, the limb and the wound.

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)
• Assessment of the limb looking for sign of venous and arterial disease
• 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)
• Assessment of the wound including location, duration, size, tissue type, assessment of wound edge and surrounding skin

If your patient has any indication of arterial disease then urgently referral to vascular specialist is required to assess the need for revascularisation and advice on level of appropriate compression therapy.

If your patient has a leg wound with adequate arterial supply and no other aetiology other than venous insufficiency, then the patients should be commenced on strong compression therapy and MUST be referred to vascular specialist to assess the need for intervention to help ‘cure’ the underlying venous disease.

Download a pdf about vascular referral

Treatment for venous leg ulcers

The first line treatment for venous ulceration is strong compression therapy – the following should be taken into consideration:

• All patients with venous ulceration need to be referred to vascular services to undergo assessment of veins as per NICE guidelines (web link) and National Wound Care Strategy Programme recommendations (PDF download)
• People with the below conditions should be offered strong multi-component compression bandaging in the form of two-layer compression hosiery kits as first line treatment. The need for application aids should be considered:
  • Chronic ankle/leg oedema not reduced by elevation
  • Abnormal limb shape
  • Copious exudate
  • Very fragile skin
• Dressings should be low adherent but with sufficient absorbency
• 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 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

When to refer for assistance

People with wounds that show no significant progress towards healing or are deteriorating should be escalated to the local Specialist Service for advice.

Where possible, self-care should be encouraged, supported by the Local Care Team under the supervision of the Specialist Team.

When wounds are progressing to healing but remain unhealed, a comprehensive re-assessment should be undertaken.

General health advice for patients with leg ulceration

There are some lifestyle changes patients can make that will help boost healing:

• Maintaining a healthy weight
• Eating a well-balanced diet that includes 5 portions of fruit and vegetables a day and protein rich foods such as eggs, fish, chicken or pulses
• Taking light to moderate exercise such as cycling or walking for about thirty minutes at least three times a week
• Avoiding standing or sitting for long periods of time
• Putting their feet up – legs to be elevated above the heart.

Publications & Evidence for venous leg ulcers

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

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Clinical guidelines for venous leg ulcers

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

• National Wound Care Strategy Programme recommendations (PDF download)
• The SIGN guideline is the most recent UK clinical guideline (PDF download)
• The Royal Society of Medicine Venous Forum has produced a useful one page guide to managing venous leg ulceration (PDF download)

Patient information for venous leg ulcers

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

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Dowload a patient information leaflet as a pdf to print