ONLINE GUIDE
Leg Ulcers – Compact Guide 2024
Prof Mark Whiteley
The Whiteley Clinic, Guildford
Quality check
Written according to scientific standards by medical experts Last updated 22.03.2024 Reading time approx. 9 minutes
Leg Ulcers in a Nutshell
A leg ulcer is a wound on the lower leg that heals slowly or not at all. The open wound is exposed to an increased risk of infection, as pathogens can penetrate the underlying tissue.
Essentially, a leg ulcer is a symptom of an underlying disease. If there is a chronic venous disease, it is referred to as a venous leg ulcer. If a patient has calcified arteries, doctors call it an arterial leg ulcer. If both issues have caused the ulcer, it is referred to as an arterial-venous leg ulcer.
More than half of the patients with leg ulcers are diagnosed with the venous type of leg ulcer.1 Those affected may have varicose veins or deep vein thrombosis, for example, which leads to the venous condition. If a wound develops in the lower leg, it heals slowly or not at all. The persistent blood retention in the legs prevents an adequate supply of nutrients. For affected patients, a lower leg ulcer often means pain, itching, swelling and weekly visits to the doctor to change the wound dressing and reapply the compression bandage.
The treatment options for leg ulcers have improved in the past few decades but are still limited. However, research is currently developing new and innovative therapeutic approaches. The aim is to help people who suffer from leg ulcers and have not yet found an optimal therapy.
In this guide, you will find practical information that can be useful for dealing with leg ulcers.
Contents
Overview
Leg Ulcer Profile
Key facts about leg ulcers:
A leg ulcer never develops “on its own”. The basic prerequisite is often a circulatory disorder in the legs.
This circulatory disorder is usually caused by chronic venous insufficiency (short: CVI) or peripheral arterial occlusive disease (short: PAD).
Leg ulcers rarely occur before the age of 40. From the age of 75, the risk of developing the disease increases significantly.
Women are affected more frequently than men.4
The wound often extends into deeper layers of tissue, sometimes even to the bone.
Treatment, prevention, and prognosis vary depending on the underlying disease that caused the leg ulcer.
Are you interested in new treatment options? Find out more under “New Treatments”.
Find out more about new treatments now →
Leg ulcer patients can now participate in a trial with a new active ingredient.
Find out more about our Leg Ulcer Study →
Background Knowledge
What Exactly Are Leg Ulcers?
A leg ulcer is a lower leg wound that heals poorly or doesn’t heal. There are different types of leg ulcers, each with quite different risk factors. However, in most cases, blood flow is impaired, resulting in affected tissue becoming damaged over time.
Venous leg ulcers
Chronic venous insufficiency (CVI for short) can result in venous leg ulcers. In case of venous insufficiency, blood does not properly flow back into the heart because, for example, the venous valves no longer function sufficiently. This can lead to an increased nutrient-poor, venous blood pressure in the leg. As a result, the tissue is no longer adequately supplied with the nutrients it needs for the healing process. The doctor diagnoses a venous leg ulcer if the venous insufficiency causes an open chronic wound that extends at least into the subcutaneous layer.2
Arterial leg ulcers
Arterial-venous leg ulcers (mixed ulcers)
Although this type of leg ulcer is very rare, some people suffer both from CVI and PAD. If they develop leg ulcers, the symptoms of a venous leg ulcer and an arterial leg ulcer can intertwine. Experts refer to this mixed form as an arterial-venous ulcer.
Other subtypes of leg ulcers
Doctors may also specify your leg ulcer based on its leading causes such as:
- varicose veins
- post-thrombotic syndrome
- trauma
- cancer
- infection
Info table: venous vs. arterial
Venous leg ulcers | Arterial leg ulcers | ||
|---|---|---|---|
Initial condition | Chronic venous insufficiency (CVI) | Peripheral arterial occlusive disease (PAD) | |
Problem | Reflux of nutrient-poor, venous blood | Flow of nutrient-rich, arterial blood occluded | |
Typical location of the wound | On the inside of the lower leg or the inner or outer ankle | On the outer edges of the foot, on the shin or the side of the lower leg | |
Colour of the wound | Brown, blue, black | Red, yellow, black | |
Appearance around the wound | Water retention in tissue, pigmentation of the skin | Pale, cold skin | |
Edge of wound | Irregular, flat | Well-demarcated, “punched out” | |
Depth of the wound | Superficial to deep | Deep | |
Fluid leakage | Strong | Little | |
Pulse measurable on foot | Yes | Not always palpable | |
Pain | None to intermediate | Intermediate to strong | |
Pain relief | Keep legs elevated | Keep legs lowered |
Are you interested in new treatment options? Find out more under “New Treatments”.
Find out more about new treatments now →
Leg ulcer patients can now participate in a trial with a new active ingredient.
Find out more about our Leg Ulcer Study →
Causes and Risk Factors
How Do Leg Ulcers Occur?
Poor circulation promotes the development of leg ulcers, caused by damaged arteries or veins. Hence, the development of leg ulcers depends on the type of damage blood vessel involved.
How do venous leg ulcers develop?
A venous leg ulcer is the final stage of a long chain reaction. Every patient diagnosed with venous leg ulcers has suffered from venous insufficiency for some time.
What is Chronic Venous Insufficiency (CVI)?
The most apparent symptom of venous insufficiency is varicose veins, where the veins elongate and become knotty, causing blood to flow poorly back to the heart. As a result, blood pools in the lower leg area, leading to increased water leakage into the surrounding tissue. in which the veins become elongated and bulge out in nodules. This accumulation of fluids in the tissue is called oedema. If they persist over time, the connective tissue around the oedema hardens, which is also known as sclerosis. If this condition remains unchanged over time, ulcers can form.6
Risk Factors for CVI
- Obesity
- Sudden heat exposure (saunas or hot baths)
- Predominantly sedentary or standing, monotonous activities
- Alcohol
- Tight clothing or high heels
- Old age
- Genetic predisposition
- Hormonal changes, e.g., during pregnancy
- Thromboses2
Stages of CVI
CVI develops slowly and is often recognizable in its early stages if you know what signs to look for. CVI is divided into three stages:
- Stage I: Temporary swelling of the feet and lower legs and bluish veins at the edge of the foot (an indication of fluid retention)
- Stage II: Permanent swelling and oedema of the legs and feet. Bluish or brownish colouring. Painful hardening of the tissue
- Stage III: A venous leg ulcer develops due to insufficient blood circulation2
How do arterial leg ulcers develop?
In the case of arterial leg ulcers, tissue is insufficiently supplied with nutrients and oxygen due to peripheral arterial occlusive disease (PAD).
What is PAD?
PAD is a severe condition, as it often affects other arteries in addition to the lower legs. In addition to having an increased risk of developing a leg ulcer, patients are also at an increased risk of suffering an ischaemic stroke or a heart attack, for example.
Risk factors for PAD
- Smoking
- Type 2 diabetes
- Being overweight
- High LDL cholesterol levels
- High blood pressure
- Old age
- Genetic predisposition
- Type 1 diabetes7
Stages of PAD
PAD can be categorised into different stages. The categorisation is based on the patient’s stage of claudication.
- Stage I: No obvious symptoms
- Stage IIa: Leg pain only if muscles are exercised
- Stage IIb: Simple leg movements cause pain (moderate to severe claudication)
- Stage III: Permanent (ischaemic) pain at rest
- Stage IV: An arterial leg ulcer has developed7
Symptoms
Not Always Associated with Pain
A leg ulcer is a (usually deep) wound that, unlike a typical injury, does not heal on its own. In extreme cases, the wound can even extend to the bone. In most patients, the wound is constantly moist. The oozing fluid softens the edges of the wound. A distinction must also be made regarding symptoms between the two primary forms of leg ulcers.
Symptoms of venous leg ulcers:
The wounds are typically located below the knee on the inside of the thigh but can also be located on the outer ankle joint. In some cases, the ulcer may wind around the entire leg. The pain is usually mild to minimal if the wound is not infected. The following symptoms may also occur:
- Brown, blue or black discoloured skin
- Mucous discharge
- Swelling
- Inflammation
- Itchy, hardened skin
- Scaling5
Symptoms of arterial leg ulcers:
The term “leg ulcer” is somewhat misleading for arterial leg ulcers since they usually develop on the foot, heel, or toes rather than the lower leg. However, leg ulcers can also occur in other places. The wounds often look as if the skin has been “punched out” with a cookie cutter. An arterial leg ulcer is significantly more painful than a venous leg ulcer and is often characterised by the following symptoms:
- Red, yellow or black wound
- Deep wound
- Affected area feels cold
- Tight, hairless skin
- The leg reddens upon dangling and turns pale upon elevation5
Are you interested in new treatment options? Find out more under “New Treatments”.
Find out more about new treatments now →
Leg ulcer patients can now participate in a trial with a new active ingredient.
Find out more about our Leg Ulcer Study →
Diagnosis
A Glance Is Usually All It Takes
As leg ulcers often develop in the final stage of CVI or PAD and the symptoms are unmistakable, diagnosis is mostly quickly established. Most GPs recognise a leg ulcer at first glance and know how to distinguish a chronic leg ulcer from an ordinary wound.
Medical history
Diagnosing the disease itself is not enough. Healing the patient requires more than just applying bandages and treating the disease superficially. Doctors must determine the causes so that possible treatment options can be considered.
To do this, the GP will usually start by taking your medical history to get a detailed picture of your current situation. For example, they will ask you:
- When did you first notice the wound?
- Has the wound become larger or smaller in the last few weeks?
- Is the wound painful?
- Have you already been diagnosed with CVI or PAD?
- Do you experience pain while walking
More detailed examination of the wound and the underlying vessels
After or during the medical history, the doctor will examine the wound and check the tissue for hardening or discharge. In addition, they may arrange for an ultrasound examination or conduct one on the spot. Through ultrasound, your GP can get a clearer picture of the affected area inside the leg and visualise vessels such as veins or arteries.4 This enables them to recognise which circulatory disorder is present if previously unclear.
Blood tests
With the help of a blood test, the doctor can quickly determine whether diabetes mellitus is present. If so, they will also consider treating diabetes as part of the treatment plan.
Bacterial swabbing
If the wound looks swollen and oozes more than usual, or if other clinical signs of an infection are present (e.g., fever), your ulcer may be infected. Your doctor will likely swab your wound after cleaning and send this sample to a laboratory for analysis. Identifying pathogens in the wound and surrounding tissue is crucial to prescribing the right antibiotics. Your doctor can only give you the proper therapy if they have the positive results from the bacterial swabbing.2
Are you interested in new treatment options? Find out more under “New Treatments”.
Find out more about new treatments now →
Leg ulcer patients can now participate in a trial with a new active ingredient.
Find out more about our Leg Ulcer Study →
Course and Prognosis
Prospects of Recovery
A treated venous leg ulcer generally heals better and faster (usually within 4 months) than an arterial leg ulcer. However, the relapse rate is significantly higher with this form.9
As with most diseases, consistent therapy and follow-up treatment is crucial to heal a leg ulcer and prevent recurrences. The patient’s age is essential to the prognosis, as wound healing has already slowed in older people. In these cases, a leg ulcer may even take several years to heal. Sometimes, there is no improvement at all.
Patients can take specific measures themselves to improve their healing outcomes:
- Regardless of whether arterial or venous, regular and sufficient exercise promotes blood circulation in the legs.
- In the case of venous leg ulcers, thorough compression therapy can improve blood circulation and thus have a decisive influence on the course of the disease.
- To ensure healthy blood circulation, you should avoid typical risk factors that can promote the development of leg ulcers, such as smoking or being overweight.
Treatment and Care
Thorough Handling for Optimal Wound Treatment
Leg ulcers and their causes are often difficult to treat. Diagnostic assessment, which includes the patient’s vascular, metabolic, and physical circumstances, is essential at the start of treatment. Therapy is often lengthy, and several treatment methods must be combined.
The goals of each treatment include:
- Promoting blood circulation and improving venous return, e.g., through compression therapy
- Eliminating or treating the triggering cause, e.g., through surgical interventions
- Promoting healing, e.g., with wound care, lifestyle improvement, symptom control, alleviation of symptoms
- Preventing exacerbation, e.g., medical education of the affected person
- Maintaining optimum moisturisation of the wound tissue2
Compression therapy
Wound cleaning
Healthcare professionals must clean the open wound regularly. They will apply specific wound solutions to disinfect the wound. Alternatively, they may also carry out debridement to scrape off the deposits on the wound surface and cleans the wound.
Once the slough has been successfully removed, compresses with antibacterial agents can help kill off any pathogens, if necessary.
Larval therapy
Surgical treatment
Modern surgical procedures are sometimes used to achieve one or more of the treatment goals mentioned above.
Surgery for venous leg ulcers
Varicose veins indirectly cause a venous leg ulcer. There are several methods to remove varicose veins surgically:
- Vein Stripping: Surgeons make incisions just below the groin (upper incision) and at the ankle or in the hollow of the knee (lower incision). The vein is tied off at the upper incision. A wire is inserted at the lower incision and slowly advanced. There is a bulky attachment at the lower end of the wire. This allows the vein to be pulled out entirely via the upper incision.12
- Phlebectomy: Phlebectomy works in a similar way to vein stripping. However, several tiny incisions are made, and parts of the vein are removed step by step. The procedure primarily comes into play for smaller varicose veins (often the side branches of larger varicose veins). This relatively new method heals quicker than typical vein stripping.
- Sclerotherapy: Liquid is injected into the affected vein. The active ingredient damages the vein wall, which is then transformed into connective tissue. The vein is thus permanently sealed. However, sclerotherapy can sometimes leave permanent skin discolouration at the injection site or lead to vein inflammation.
Surgery for arterial leg ulcers
Like many arterial diseases, arterial leg ulcers can be treated with a bypass surgery.13 This involves creating a new tube for the blood flow in your leg and foot that bypasses the narrowed or blocked section of the artery. The new tube can be artificial, or a graft taken from a vein in your leg or arm. Another option is to “dilate” and place a wire mesh, called a stent, in the calcified section of an artery.
Drug treatment
For leg ulcers, medication does not play a central role and thus never replaces treating the cause of the ulcer. In severe cases, supplementary drug therapy is recommended. As part of this therapy, doctors will usually prescribe medication containing growth factors to stimulate wound regeneration.2
Counteracting swelling
A venous leg ulcer is usually accompanied by feet swelling (oedema) caused by fluid accumulation. If you elevate your leg, you can reduce swelling. For example, you could place a suitcase or pillow under the foot end of your mattress to elevate your legs at night.5
Treating annoying itching
Especially venous leg ulcers can cause the skin around the wound to be very itchy. This is usually stasis eczema, which can be treated with a moisturizing cream or a corticosteroid cream.
In rarer cases, the itching may also be caused by an allergic reaction, such as if you are allergic to components in the wound dressings.
Whatever the cause may be, resist the urge to scratch, as this could aggravate the condition or even cause wound infections.
Treating infected ulcers
An infected open wound is often characterised by discharge, increasing pain at the wound site and redness around the edges. In this case, antibiotics are usually prescribed to eliminate the infection. Apart from this, the usual treatment plan is strictly followed.5
Are you interested in new treatment options? Find out more under “New Treatments”.
Find out more about new treatments now →
Leg ulcer patients can now participate in a trial with a new active ingredient.
Find out more about our Leg Ulcer Study →
New Treatments
Researchers Develop Novel Therapies
Many treatments for leg ulcers are invasive or uncomfortable in the long term. There are only a few options for treating leg ulcers with medication. This is why researchers are constantly trying to develop new therapeutic approaches and active substances to treat leg ulcers.
A novel active ingredient with a potential long-term effect is now being investigated
Researchers are now investigating a new active ingredient against leg ulcers derived from stromal cells with anti-inflammatory and wound-healing properties. They are also investigating whether this active ingredient has a long-term effect and can close the wound permanently.
Certain leg ulcer patients can take part in a current clinical trial with the novel active ingredient
A multinational Phase III clinical trial called Allo-APZ2-CVU-III, also known as the “Leg Ulcer Study”, is currently investigating the efficacy and tolerability of this new investigational drug against leg ulcers. Patients can now participate in the Leg Ulcer Study if they meet specific criteria, having the opportunity to receive the new investigational drug. If you are interested in taking part in the study, you can find out more here:
Further Information
Quality guideline:
This article is based on the German guideline for evidence-based health information, “Leitlinie evidenzbasierte Gesundheitsinformation”. 14
Authors:
Priv.-Doz. Dr. med. Andreas Kerstan, Tristan Auer
Medical Review:
Birgit Schouren, Ann-Katrin Rueß, Elke Niebergall-Roth, Anna Mößmer
Date:
22.03.2024
References:
All references were accessed in March 2024.
Important note
This article contains general advice and information. It should not be used for self-diagnosis or self-treatment and does not constitute a recommendation for therapy. It does not replace consulting a doctor. For individual questions, please contact your attending doctor.
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- Neumann HAM et al. JEADV 2016;30:1843-1875.
- O’Donnell, T. F. et al. J Eur Acad Dermatol Venereol 2014; 30(11): 1843-1875
- Grey JE et al. BMJ. 2006;332(7537):347-350.
- Agale S Ulcers. 2013.
- Grey JE et al. BMJ. 2006;332(7537):347-350
- Patel SKK et al. Venous Insufficiency. 2021.
- Zemaitis MR Peripheral Arterial Disease. 2022.
- Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/17357-peripheral-artery-disease-pad, accessed 20.03.2024
- McDaniel HB et al. J Vasc Surg. 2001
- Ren S et al. World journal of clinical cases. 2020;8(21):5070-5085.
- SIGN Guideline for the management of chronic venous leg ulcers, https://www.oxfordhealth.nhs.uk/wp-content/uploads/2015/08/SIGN-Guidelines-foer-the-Management-of-Venous-Leg-Ulcers.pdf, accessed 20.03.2024
- NHS, Treatment of varicose veins, https://www.nhs.uk/conditions/varicose-veins/treatment/, accessed 20.03.202
- NICE, Management acute limb ischaemia, https://cks.nice.org.uk/topics/peripheral-arterial-disease/management/acute-limb-ischaemia/, accessed 20.03.2024