Venous leg ulcers

Overview – why is my venous leg ulcer not healing?

We all damage our legs from time to time. It’s easy to knock our leg on a car door or shopping trolley, or sometimes an insect bite can turn into a wound or leg ulcer.

Traditionally venous leg ulcers we’re viewed as only be common in older people – this isn’t correct and is a bit of an old wives tale. Anyone, at any age can get a leg ulcer, often there may be an underlying condition which may make you more likely to suffer with a leg ulcer. The most important part of treatment is that you receive compression therapy in the form of bandages, hosiery or wraps.

In healthy, normal legs, wounds should be showing signs of healing within two weeks of injury. If a wound is taking longer than a couple of weeks to show signs of healing or the wound is weeping and getting larger, then this might be a sign of an underlying problem which needs looking into.

It’s common for wounds, lacerations or surgical incision to heal more slowly on the lower leg than other areas of the body, 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.

Symptoms of venous leg ulcers

Why might a wound on the leg not heal?

This is because the wound is on the leg and is much more difficult to heal than wounds on another part of the body. We spend a lot of time on our feet and if we have any swelling, this will interfere with healing. If you stand a great deal, or you are carrying excessive weight, this will not help your venous circulation. Any wound, except those caused by arterial disease (see below) will benefit and heal more swiftly from some form of compression therapy. Do not ignore this even if pain is minimal.

What to look out for

• Oedema – swell of the leg
• Skin changes such as colour or texture
• Visible varicose veins
• Itchy areas on the ankle

What do leg ulcers look like?

Diagnosis – getting diagnosed with a venous leg ulcer and making an appointment

The sooner you get treatment the more likely you will heal. You need an appointment with a nurse or a GP. Often nurses are responsible for caring for patients with leg problems. Make sure you remove any nail varnish before your appointment.

Things to say when booking your appointment:

• If your wound is hot or red, this may be urgent and require care immediately
• How the wounding happened or whether it just spontaneously started
• Make it clear if you have diabetes
• Make it clear that the wound has not healed within two weeks and it’s worrying
• Let them know if it smells or if it’s painful and what makes this better or worse

If you’re struggling to get an appointment with your GP, there might be a Leg Club or specialist leg clinic in your area. You can attend these without having to be referred.

What to expect at your appointment

Medical history – your GP or practice nurse will try to determine the cause of the ulcer by asking about underlying conditions or previous injuries, such as:

• Diabetes
• Deep vein thrombosis (DVT)
• Injury or surgery in the affected leg
• A previous leg ulcer

Examination – they’ll ask whether you have any other symptoms associated with venous leg ulcers and should perform an thorough examination, this should be done stood up and lying down. They should:

• Ask about your symptoms and how long you have had problems
• Examine your lower legs to check for redness, swelling and / or signs of infection, pus, signs of heat;
• Check you don’t have an infection like sepsis or cellulitis
• Measure and check for the size of the leg ulcer and perform an assessment of wound edge and surrounding skin

Tests – your GP or practice nurse should perform some simple tests

• Doppler ultrasound – this test compares blood flow in your ankle with that in your arm to find out if there are blood flow problems in your lower leg
• In complicated cases you may need to have an ultrasound scan, CT scan or MRI scan to produce a detailed map of the blood circulation in your leg
• Other tests – this could include tests to check for other health problems that can affect your legs such as diabetes, lymphoedema, oedema, sepsis or cellulitis and anaemia

Language used – you may hear different words to describe your wound such as ulcer, leg ulcer, sore, laceration, chronic wound and maybe others. Ask your nurse to explain their choice of word and what this may mean for you.

Treatment and referral options for venous leg ulcers

Compression therapy (support bandages or socks)

If your wound isn’t healing because of venous hypertension and there are no problems with the blood supply to your legs, then you must be offered compression therapy.

Compression therapy improves the return of your venous blood supply by applying pressure to the leg and foot. This can be done by bandaging the lower leg or by wearing supportive socks, stockings or tights. Compression therapy is very effective at reducing swelling, improving blood flow in the veins and healing or preventing sores or ulcers. Compression therapy also reduces the inflammation around the wound thereby reducing pain and also the skin changes.

There are lots of different types of compression therapy so ask your nurse to find something that is right for you.

Compression can be a little uncomfortable when you first start treatment but should not cause you any pain. Any discomfort should reduce as the swelling goes down. If you do experience discomfort, talk to your nurse or doctor about it and they will advise you on ways of alleviating this.

In addition to the compression, your nurse should also advise you on wound care and dressings to keep your wound healthy. If you are self-managing with hosiery or socks, then you should expect a treatment plan that includes what you need to do, how to recognise concerns and treatment check ins with the nurse.

Getting a referral to a specialist

You may be referred if your GP or nurse is unsure about your diagnosis, or if they suspect your ulcer may be caused by a diseases or underlying condition.

Vascular referral – if you have venous hypertension, surgical intervention from a vascular specialist might help with healing and stop your wound or sore from coming back. Sometimes varicose veins can be treated by laser therapy. If you have peripheral arterial disease, you may require further investigations and the vascular team will be able to assess the need to improve the blood supply to your leg or whether your ulcer can be managed in other ways such as reduced/modified compression.

Tissue Viability – a Tissue Viability Nurse is a specialist nurse for complex wounds. If your wound is non-healing or is very painful, or you cannot tolerate the compression therapy, please ask for a referral to this nurse.

Here are some possible questions you could ask about being referred for tests:

• Is the doctor or nurse I will be seeing a tissue viability or a vascular specialist?
• When will I be seen? Are you referring me as urgent or non-urgent?
• When will I have the tests?
• What are the tests for and what will they involve?
• Will the person doing the test look after me while it is being done and tell me what to expect?
• Who will give me the results and when?

Up to seven in 10 venous ulcers heal within 12 weeks if treated with compression therapy. If compression is not used the chance of healing is less.

Prevention – how to prevent the recurrence of venous leg ulcers

Venous leg ulcers commonly come back (recur) after they have healed. To prevent this, you should wear a support (compression) stocking during the daytime for at least five years after the ulcer has healed. This counteracts the raised pressure in the veins that causes venous leg ulcers. You should get a new stocking about every six months as the elastic tends to relax after a while. Compression stockings can be prescribed by the Nurse or GP or bought at pharmacies. They come in different sizes – your pharmacist will advise. Compression stockings for the prevention of venous leg ulcers are usually below knee in length rather than thigh length.

How to prevent getting and how to help heal venous leg ulcers

There are some lifestyle changes you can make that will help boost healing and help prevent getting a leg ulcer in the first place:

• Maintain a healthy weight. Extra weight puts a lot of pressure on abdominal veins, creating problems for your legs.
• Eat a well-balanced diet that includes five portions of fruit and vegetables a day and protein rich foods such as eggs, fish, chicken or pulses
• Take light to moderate exercise such as cycling or walking for about thirty minutes at least three times a week
• Avoid standing or sitting for long periods of time
• Put your feet up – elevate your legs above your heart
• Every so often, move your feet around in circles, then up and down. This helps blood circulate and get back to your heart
• Do not sleep in a chair overnight

There are different strengths (classes) of compression stockings – class 1, 2 and 3. The higher the class (class 3) the greater the compression. Ideally, wear class 3 stockings. However, some people find class 3 stockings too tight and uncomfortable but class 2 may be fine. It is still better to wear some sort of compression stocking than none at all.

Note: proper compression stockings used for medical purposes are different to the support stockings or tights sold in ordinary clothing shops.

A leg venous ulcer is much less likely to recur if you wear compression stockings regularly.

Sometimes surgery for varicose veins or other vein problems is advised after an ulcer has healed, in order to help prevent a recurrence.

Harm – the risk factors

Inaction or insufficient action on venous leg ulcers can cause harm. This includes:

• Not checking legs properly or doing basic checks, such as a Doppler test
• Not performing a vascular assessment to determine if suitable for compression
• Not using adequate compression if indicated, can lead to worsening disease
• Not being referred to vascular services for venous intervention if required

If you have any concerns about the treatment or care you are receiving, it is important to speak up.

Learn more about harm