Venous leg ulcer

A leg ulcer is a long-lasting (chronic) sore that takes more than 4 to 6 weeks to heal. They usually develop on the inside of the leg, just above the ankle.

The symptoms of a venous leg ulcer include pain, itching and swelling in the affected leg. There may also be discoloured or hardened skin around the ulcer, and the sore may produce a foul-smelling discharge.

See your GP if you think you have a leg ulcer, as it will need specialist treatment to help it heal.

Your GP will examine your leg and may carry out additional tests to rule out other conditions.

Read more about how a venous leg ulcer is diagnosed.

What causes venous leg ulcers?

A venous leg ulcer is the most common type of leg ulcer, accounting for over 90% of all cases.

Venous leg ulcers can develop after a minor injury, where persistently high pressure in the veins of the legs has damaged the skin.

Read more about the causes of venous leg ulcers.

Who's affected?

Venous leg ulcers are estimated to affect around 1 in 500 people in the UK, although they become much more common with age. It's estimated that around 1 in 50 people over the age of 80 has one.

You're more at risk of developing one if you've previously had deep vein thrombosis (DVT) or find it difficult to walk because of a problem such as:

• osteoarthritis
• a leg injury
• obesity
• paralysis

You're also more at risk if you've recently had an operation on your leg, such as a hip replacement or knee replacement.

People with varicose veins (swollen and enlarged veins) also have a higher risk of developing venous leg ulcers.

How venous leg ulcers are treated

Most venous leg ulcers heal within 3 to 4 months if they're treated by a healthcare professional trained in compression therapy for leg ulcers. However, some ulcers may take longer to heal, and a very small number never heal.

Treatment usually involves:

• cleaning and dressing the wound
• using compression, such as bandages or stockings, to improve the flow of blood in the legs

Antibiotics may also be used if the ulcer becomes infected, but they don't help ulcers to heal.

However, unless the underlying cause of the ulcer is addressed, there's a high risk of a venous leg ulcer recurring after treatment. Underlying causes could include immobility, obesity, previous DVT, or varicose veins.

Read more about treating venous leg ulcers.

Can venous leg ulcers be prevented?

There are several ways to help prevent a venous leg ulcer in people at risk, such as: 

• wearing compression stockings
• losing weight if you're overweight
• exercising regularly
• elevating your leg when possible

This is particularly important if you've previously had a leg ulcer – once a leg has suffered a venous ulcer, you're at risk of further ulcers developing within months or years.

Read more about preventing venous leg ulcers.

Venous leg ulcers are open, often painful, sores in the skin that take more than a month to heal. They usually develop on the inside of the leg, just above the ankle.

If you have a venous leg ulcer, you may also have:

• swollen ankles (oedema)
• discolouration and darkening of the skin around the ulcer
• hardened skin around the ulcer, which may make your leg feel hard or even resemble the shape of an upside-down champagne bottle
• a heavy feeling in your legs
• aching or swelling in your legs
• red, flaky, scaly and itchy skin on your legs (varicose eczema)
• swollen and enlarged veins on your legs (varicose veins)
• an unpleasant and foul-smelling discharge from the ulcer

Signs of an infection

A venous leg ulcer can be susceptible to bacterial infection. Symptoms of an infected leg ulcer can include:

• worsening pain
• a green or unpleasant discharge coming from the ulcer
• redness and swelling of the skin around the ulcer
• a high temperature (fever)

When to seek medical advice

Contact your GP if you think you've developed a venous leg ulcer. They're unlikely to get better on their own, as they usually require specialist medical treatment.

You should also contact your GP or leg ulcer specialist if you've been diagnosed with a venous leg ulcer and have symptoms that suggest it could be infected.

Read more about how venous leg ulcers are treated.

A venous leg ulcer can develop after a minor injury if there's a problem with the circulation of blood in your leg veins. If this happens, pressure inside the veins increases.

This constant high pressure can gradually damage the tiny blood vessels in your skin and make it fragile. As a result, your skin can easily break and form an ulcer after a knock or scratch.

Unless you have treatment to improve the circulation in your legs, the ulcer may not heal.

Read more about treating venous leg ulcers.

Who's most at risk?

A number of factors can increase your risk of developing a venous leg ulcer, including:

• obesity or being overweight – this increases the pressure in the leg veins
• if you have difficulty walking – this can weaken the calf muscles, which can affect circulation in the leg veins
• previous deep vein thrombosis (DVT) – blood clots that develop in the leg can damage valves in the veins
• varicose veins – swollen and enlarged veins caused by malfunctioning valves
• previous injury to the leg, such as a broken or fractured bone, which may cause DVT or impair walking
• previous surgery to the leg, such as a hip replacement or knee replacement, which can prevent you from moving about
• increasing age – people find it harder to move around as they get older, particularly if they suffer from arthritis

See your GP if you think you have a venous leg ulcer. The ulcer is unlikely to heal without specialist treatment.

Diagnosis is largely based on your symptoms and examination of your affected leg, although additional tests may be required.

Medical history and examination

Your GP or practice nurse will ask whether you have any other symptoms associated with venous leg ulcers, such as:

• swelling in your ankles
• discoloured or hard skin

They'll 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

They'll also examine your leg, both when you're standing up and lying down. Varicose veins will be more obvious when you're standing up, and it will be easier to look at the ulcer when you're lying down.

They'll also feel your pulse at your ankles to make sure the arteries in your leg are working properly.

Doppler study

To rule out peripheral arterial disease (a condition affecting the arteries) as a possible cause of your symptoms, your GP or nurse will carry out a test known as a Doppler study.

This involves measuring the blood pressure in the arteries at your ankles and comparing it to the pressure in your arms. If you have peripheral arterial disease, the blood pressure in your ankles will be lower than your arms.

It's important to carry out this check as the main treatment for venous ulcers is compression bandages or stockings to improve the vein circulation in your legs. It's not safe to apply compression if the ankle artery pressures are low.

Read more about how venous leg ulcers are treated.

Referral to a specialist

In some cases, your GP or nurse may decide to refer you to a specialist in conditions affecting the blood vessels (vascular specialist).

For example, you may be referred to a vascular specialist if your GP or nurse is unsure about your diagnosis, or if they suspect your ulcer may be caused by artery diseases, diabetes or rheumatoid arthritis.

After taking your medical history and examining you, the vascular specialist may need to arrange further investigations to plan your treatment.

With appropriate treatment, most venous leg ulcers heal within 3 to 4 months.

Treatment should always be carried out by a healthcare professional trained in compression therapy for leg ulcers. Usually, this will be a practice or district nurse.

Cleaning and dressing the ulcer

The first step is to remove any debris or dead tissue from the ulcer and apply an appropriate dressing. This provides the best conditions for the ulcer to heal.

A simple, non-sticky dressing will be used to dress your ulcer. This usually needs to be changed once a week. Many people find they can manage cleaning and dressing their own ulcer under the supervision of a nurse.

Compression

To improve vein circulation in your legs and treat swelling, your nurse will apply a firm compression bandage over the affected leg. These bandages are designed to squeeze your legs and encourage blood to flow upwards, towards your heart.

There are many different types of bandage or elastic stockings used to treat venous leg ulcers, which may be made in 2, 3 or 4 different layers. The application of a compression bandage is a skilled procedure and they should only be applied by trained healthcare staff.

The bandage is changed once a week, when the dressing is changed.

When compression bandages are first applied to an unhealthy ulcer, it's usually painful. Ideally, you should have paracetamol or an alternative painkiller prescribed by your GP. The pain will lessen once the ulcer starts to heal, but this can take up to 10-12 days.

It's important to wear your compression bandage exactly as instructed. If you have any problems, it's usually best to contact your nurse, instead of trying to remove it yourself. If the compression bandage feels a little too tight and is uncomfortable in bed at night, getting up for a short walk will usually help.

However, you'll need to cut the bandage off if:

• you get severe pain at the front of your ankle
• you get severe pain on the top of your foot
• your toes become blue and swollen

Once you remove the bandage, make sure you keep your leg highly elevated and contact your doctor or nurse as soon as possible.

In some clinics, specialist teams are using new alternatives to compression bandages, such as special stockings or other compressive devices. These may not be available in every clinic but could change the way ulcers are treated in future. Your specialist will be able to advise you whether a different approach may help you.

Treating associated symptoms

Swelling in the legs and ankles

Venous leg ulcers are often accompanied by swelling of your feet and ankles (oedema), which is caused by fluid. This can be controlled by compression bandages.

Keeping your leg elevated whenever possible, ideally with your toes at the same level as your eyes, will also help ease swelling. You should put a suitcase, sofa cushion or foam wedge under the bottom of your mattress, to help keep your legs raised while you sleep.

You should also keep as active as possible and aim to continue with your normal activities. Regular exercise, such as a daily walk, will help reduce leg swelling. However, you should avoid standing or sitting still with your feet down. You should elevate your feet at least every hour.

Itchy skin

Some people with venous leg ulcers develop rashes with scaly and itchy skin.

This is often due to varicose eczema, which can be treated with a moisturiser (emollient) and occasionally a mild corticosteroid cream or ointment. In rare cases, you may need to be referred to a dermatologist (skin specialist) for treatment.

Itchy skin can also sometimes be caused by an allergic reaction to the dressings or creams applied by your nurse. If this happens, you may need to be tested for allergies.

It's important to avoid scratching your legs if they feel itchy, because this damages the skin and may lead to further ulcers.

Looking after yourself during treatment

To help your ulcer heal more quickly, follow the advice below:

• Try to keep active by walking regularly. Sitting and standing still without elevating your legs can make venous leg ulcers and swelling worse
• Whenever you're sitting or lying down, keep your affected leg elevated – with your toes level with your eyes
• Regularly exercise your legs by moving your feet up and down, and rotating them at the ankles. This can help encourage better circulation
• If you're overweight, try to reduce your weight with a healthy diet and regular exercise
• Stop smoking 
• Moderate your alcohol consumption
• Be careful not to injure your affected leg, and wear comfortable, well-fitting footwear

You may also find it helpful to attend a local healthy leg club, such as those provided by the Lindsay Leg Club Foundation, for support and advice.

Treating an infected ulcer

An ulcer sometimes produces a large amount of discharge and becomes more painful. There may also be redness around the ulcer. These symptoms and feeling unwell are signs of infection.

If your ulcer becomes infected, it should be cleaned and dressed as usual.

You should also elevate your leg most of the time and you'll be prescribed a 7-day course of antibiotics.

The aim of antibiotic treatment is to clear the infection. However, antibiotics don't heal ulcers and should only be used in short courses to treat infected ulcers.

Follow-up

You should visit your nurse once a week to have your dressings and compression bandages changed. They'll also monitor the ulcer to see how well it's healing. Once your ulcer is healing well, your nurse will see you less often.

After the ulcer has healed

Once you've had a venous leg ulcer, another ulcer could develop within months or years.

The most effective method of preventing this is to wear compression stockings at all times when you're out of bed. Your nurse will help you find a stocking that fits correctly and that you can manage yourself.

Various accessories are available to help you put them on and take them off.

Read more about preventing venous leg ulcers.

You can help reduce your risk of developing a venous leg ulcer in several ways, such as wearing a compression stocking, losing weight and taking care of your skin.

People most at risk of developing a venous leg ulcer are those who have previously had a leg ulcer.

Compression stockings

If you've previously had a venous leg ulcer, or you're at risk of developing one, treatment with compression stockings may be recommended by your GP.

These stockings are specially designed to squeeze your legs, improving your circulation. They're usually tightest at the ankle and less tight further up your leg – this encourages blood to flow upwards, towards your heart.

To be most effective, these stockings should be put on as soon as you get up and only taken off at night.

Compression stockings are available in a variety of sizes, colours, styles and pressures. A nurse can help you find a stocking that fits correctly and that you can manage yourself. There are various accessories you can buy to help get the stockings on and off.

Losing weight

If you're obese or overweight, losing weight can help treat and prevent venous leg ulcers. Excess weight leads to high pressure in the veins in your legs, which can damage your skin. Venous ulcers are much more common among people who are overweight.

To help you lose weight, regular exercise and a healthy, balanced diet are recommended. You should also avoid sitting or standing for long periods. Elevating your legs whenever possible can also help.

Read more about:

• losing weight 
• health and fitness
• healthy eating

Treating underlying problems

Treating severe varicose veins may help prevent leg swelling or ulcers. This may involve a procedure where a catheter (a thin, flexible tube) is inserted into the affected veins with high-frequency radio waves or lasers used to seal them.

Alternatively, you may need surgery to repair the damage to your leg veins, or to remove the affected veins altogether.

Read more about treating varicose veins.