Venous leg ulcer
This is an open wound on the lower leg that fails to close for weeks and months. It usually appears on the inner side of the leg, just above the ankle, and…
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Medicines commonly prescribed for Venous leg ulcer
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: CREAM, 2 %Active substance: fusidic acidManufacturer: Laboratorios Leo Pharma S.A.Prescription requiredDosage form: CREAM, 20 mg/gActive substance: fusidic acidManufacturer: Redox Farma S.L.U.Prescription requiredDosage form: CREAM, 2%Active substance: fusidic acidManufacturer: Isdin S.A.Prescription required
This is an open wound on the lower leg that fails to close for weeks and months. It usually appears on the inner side of the leg, just above the ankle, and the cause lies not in the wound but in the veins: blood struggles to travel upwards, the pressure inside them stays high, and the skin above becomes so fragile that it splits after a trivial knock and then will not heal.
This is the commonest kind of leg ulcer and accounts for most cases. It becomes far more frequent with age, and in anyone who has had one before, the chance of another is high even years later. The whole subject comes down to a single idea: treat the veins, not the wound. Dressings alone, with nothing done about the venous return, will not close an ulcer.
Why it appears
Blood travels up from the legs against gravity. The muscle pump drives it: with every step the calf squeezes the deep veins, and valves inside the veins stop the blood slipping back. If those valves are wrecked or the muscles barely work, blood pools, pressure in the small vessels of the skin rises, and fluid and blood cells leak through their walls into the tissue. The skin swells, darkens, hardens and loses its ability to repair itself.
The usual routes to this are:
- a past deep vein thrombosis — the clot damages the valves, and the consequences sometimes show up many years later;
- varicose veins;
- difficulty walking from arthritis, the after-effects of a stroke or a stiff ankle: the muscle pump stops working;
- a fracture or an operation on the leg, including hip and knee replacement, after which someone is immobile for a long stretch;
- excess weight, which raises the pressure in the veins of the abdomen and legs;
- work spent standing for hours, older age, and a previous ulcer on the same leg.
What it looks like and what happens around it
The ulcer itself is usually shallow, with ragged edges and a moist base, and fluid soaks through the dressing. Pain varies from a dragging heaviness to something severe, and it generally eases when the leg is raised.
Just as important is what happens to the surrounding skin. These changes appear long before the wound and offer a chance to step in early:
- ankle swelling that builds through the day and settles overnight;
- rusty brown staining on the skin of the shin, left behind by broken-down blood cells;
- hardening of the skin and the tissue beneath it: the leg narrows just above the ankle and takes on the shape of an upside-down bottle;
- flaky, red, itchy skin — varicose eczema;
- small white scars scattered among the pigmented areas;
- widened veins and fine thread veins around the inner ankle.
Signs that infection has set in: pain has risen sharply, redness and swelling are spreading around the wound, the skin feels hot, the temperature is up and there is a general sense of being unwell. Redness is harder to see on black or brown skin — go by the swelling, the heat and the pain.
What else can look the same
Not every leg ulcer is venous, and the difference matters: what helps one can do harm in another.
- Arterial ulcer. Usually sits on the foot, the toes or the heel, with edges that look punched out and a dry base. Pain is worse at night and lying flat, and eases when the leg hangs out of bed. The foot is cold and pale and the pulse cannot be felt. Compression here is dangerous — it can shut off a blood supply that is already meagre.
- Diabetic foot ulcer. Forms at pressure points on the sole, is often painless because the nerves are affected, and is ringed by thick callus. It needs the foot taken off-loading and follow-up in a specialist clinic.
- Ulcer from inflamed blood vessels, and pyoderma gangrenosum. Grows fast, over days, with an undermined purple edge and pain out of all proportion. Here cleaning the wound and applying compression can make matters worse: the treatment is entirely different and a specialist is needed.
- Ulcer from a skin cancer. Rare, but the most important of the rare causes: a wound that stays open for a long time can turn malignant. Raised, rolled or heaped-up edges together with a complete lack of improvement are the warning. If an ulcer is no smaller after three months of correct treatment, or simply looks unusual, a sample of tissue is taken for examination.
What the doctor checks
The diagnosis rests mainly on examination. The leg is looked at both standing and lying down: standing shows the widened veins better, lying down makes the ulcer easier to assess. The doctor asks about past thrombosis, injuries and operations on the leg, diabetes and previous ulcers.
One step is obligatory: measuring the pressure at the ankle and at the arm with an ultrasound probe. The ratio between the two shows whether the arteries are sound. Compression is not started without it — if arterial flow is reduced, a tight bandage does not heal but kills tissue. This is the single most important test in the whole subject.
Beyond that, a duplex ultrasound scan of the veins may be needed, showing which veins are letting blood run backwards and whether that can be corrected; a blood glucose test; and a biopsy where an unusual cause is suspected. A swab from the surface of the wound is not taken routinely: bacteria live in every open ulcer, and their presence alone does not call for treatment.
How it is treated
The main treatment is compression. A multilayer bandage or purpose-made compression hosiery squeezes the leg from outside, helps the blood upwards and takes down the swelling. The bandage must be applied by someone trained to do it: put on badly, it either does nothing or causes injury.
With proper compression most ulcers heal within about six months, and a good proportion sooner. The first days in a bandage can be painful; paracetamol at a dose agreed with the doctor suits this well. As healing gets under way the pain fades.
What else the treatment involves:
- cleaning slough and dead tissue from the wound and covering it with a simple non-adherent dressing. Expensive dressings do not heal faster — there is no evidence they are better, and the money does more good spent on well-fitting compression hosiery;
- changing the dressing usually one to three times a week, as it becomes soaked;
- looking after the skin around it: an emollient daily and, where there is varicose eczema, a short course of a steroid cream on the doctor's advice. If itching flares up straight after a change of dressing or cream, consider an allergy to it;
- antibiotics only where infection is clear, and as a short course. Smell and heavy discharge on their own are not grounds for them, and antibiotics do not speed up healing;
- dealing with the veins. If ultrasound shows blood running backwards through the surface veins, closing them from within by catheter — with laser, radio waves or a sclerosing agent — and doing it early speeds healing and markedly cuts the risk of the ulcer opening again. It is worth asking about: plenty of people spend years having dressings changed without their veins ever being discussed.
The most effective thing in a person's own hands is to move and to raise the leg. Walking switches on the muscle pump, and lying with the leg above hip level for half an hour several times a day takes the swelling down. A simple exercise helps too: sitting, move the feet up and down and circle them at the ankle.
When to take the bandage off and call urgently
A compression bandage must never do harm. Take it off or cut it, raise the leg and contact your doctor or nurse the same day if:
- numbness or pins and needles appear in the foot and toes;
- the pain becomes unusually severe, particularly at night;
- the toes swell, turn pale or blue, or go cold.
Be seen the same day if redness and swelling are spreading up the leg, the temperature rises and there are shivers and exhaustion — this may be cellulitis or another soft tissue infection.
Call an ambulance on the single European number 112 if the wound bleeds heavily and pressure will not stop it, if the skin around the ulcer is blackening rapidly while the pain escalates, or if someone with an infected ulcer becomes confused and their breathing and pulse suddenly race.
Keeping it from coming back
Once an ulcer has healed, the risk of another on the same leg stays for years. The veins have not gone anywhere, so prevention is not a course of treatment but a permanent routine.
- Compression hosiery. Put it on in the morning before the leg swells and take it off at night. A nurse will help you find the right size and strength; there are aids that make it much easier to get on, and they are worth asking for if your hands cannot manage.
- Walk every day and keep the ankle moving. A stiff ankle disables the muscle pump more thoroughly than any vein does.
- Raise the legs during the day and rest them on a pillow at night.
- Bring your weight down if it is high.
- Use an emollient on the skin of the lower legs daily and protect them from knocks and scratches: on skin like this even a graze can open a fresh ulcer.
- Stop smoking — it worsens the blood supply to the skin and slows healing.
- Ask a vascular surgeon whether treating the varicose veins is worthwhile. It is the one measure that removes the cause itself.
Online consultation
A remote appointment helps you work out what is happening to the leg without losing time. From your description and a photograph the doctor can judge whether the wound looks like a venous ulcer, explain which tests should come first and why compression cannot begin before the arteries are checked, go through reports you already have, advise on caring for the skin around the wound and choosing hosiery, and help you frame questions for a vascular surgeon — above all whether the venous reflux can be dealt with.
Compression cannot be applied at a distance and the pulse in the foot cannot be felt down a video call, so the first examination and the ankle pressure measurement have to be done in person in any case.
This material is for information only and does not replace medical advice.
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