Leg Ulcers

Leg ulceration is probably the most feared complication of leg vein disease.  Fortunately, venous leg ulcers do not happen quickly. If you have varicose veins or varicose eczema or symptoms of varicose veins such as aching legs, swollen ankles or ankle flare, you may be at risk of leg ulcers. Here you will find information you need to know so that you can avoid a leg ulcer. If you have a leg ulcer, you will find the information you need to get it healed quickly and to keep it healed.

What is a Leg Ulcer?

A leg ulcer describes a break in the skin, which allows air and bacteria to get into the leg. This is often caused by an injury, usually a minor one that cuts or grazes the skin.

In healthy people such an injury heals up quickly within a week or two. However, if the person has an underlying health problem, the skin does not heal and the area of breakdown can increase in size. This is what is meant by the term “chronic leg ulcer”.

What Types of Leg Ulcer are there?

The most common underlying problem causing chronic leg ulcers is disease of the veins of the leg. Venous disease is the main reason for over three quarters of all leg ulcers.

Venous Disease (caused by veins not working) – about 80% of leg ulcers (estimates vary from 75% to 90%)

Arterial Disease (caused by narrowings or blockages of the arteries) – about 15% of leg ulcers

Other causes (includes diabetes and rheumatoid arthritis as well as some rare conditions) – about 5% of leg ulcers

In some cases two or more conditions may be causing damage at the same time. At The VeinCare Centre, we specialise in the treatment of leg ulcers caused by vein problems. This type of ulcer is called a Venous Leg Ulcer.

Definition of a Venous Leg Ulcer

A venous leg ulcer is a breakdown of the skin that lasts more than 2 weeks, caused by an abnormality of blood flow in the veins, usually vein reflux in the superficial veins or blockage in the deep veins. 

What Causes a Venous Leg Ulcer?

Venous Leg Ulcers can be caused by varicose veins which have faulty vein valves. These veins are part of the superficial vein vein system located under the skin. The condition in the superficial veins which can cause leg ulcers is called superficial venous reflux. 

Deep Vein Thrombosis (DVT) affects the deep veins which are located in the muscles of the leg.  DVT can damage the deep veins valves causing deep vein reflux or the DVT may narrow the deep veins causing deep vein obstruction. 

corona-phlebectatica-ankle-flare

Spider Veins and Eczema around the Ankle Are Precursors of Leg Ulcers

Corona phlebectatica is defined as the presence of abnormally visible cutaneous blood vessels at the ankle.

In the new International Classification of Vein Disease (CEAP Classification), it is an indicator of advanced leg vein disease. In the early stages, corona phlebectatica may just look broken veins and some people seek treatment for purely cosmetic reasons.

Venous Eczema (also called varicose eczema) is an inflammatory reaction of the skin induced by back pressure in the leg veins which is transmitted to the skin. It is most often located near varicose veins, but it can be found anywhere on the leg. If left untreated, it can progress to blistering, weeping, or scaling eruption of the skin on the leg. It is a warning sign that a leg ulcer is likely to develop. As you can see in the photograph, the skin is discoloured and the areas can be intensely itchy. The condition will respond to steroid cream and the inflammation will settle. Steroid creams can be helpful to relieve intense symptoms, but as the condition is caused by underlying vein problems, these vein problems should be treated as soon as possible. Long-term use of steroid creams will thin the skin and the skin will become vulnerable to injury

How does venous disease cause ulcers?

The veins in your leg are blood vessels that carry the blood back from the foot towards your heart. The veins in your legs have one-way valves that make sure the blood flows up the leg and not back down towards the foot.

In some people, these valves are not very effective or they have been damaged by thrombosis (clots) in the veins. If the valves are faulty or damaged, blood can flow the wrong way down the veins, which results in a very high pressure in the veins when standing up. This abnormally high pressure in the veins damages the skin and leads to the ulcers.

As a result of the high back pressure in the veins, the capillaries in the skin circulation are deprived of nutrients and oxygen. Initially the skin damage looks like eczema and in the presence of varicose veins is called varicose eczema. In fact, varicose eczema is a warning sign that an ulcer is likely to develop. 

Usually an ulcer breaks down in an area of varicose eczema and often, it follows a minor injury, such as a knock from a shopping trolley.

What Does a Venous Leg Ulcer Look Like?

A venous leg ulcer usually develops on the inner or outer side of the lower calf just above the ankle bone.

It causes pain, itch and swelling of the affected leg. It can become infected with a smelly discharge. The ulcer may cause time off work and require multiple hospital appointments.

The skin around the ulcer is often discoloured and thickened. Sometimes, varicose veins can be seen close to the ulcer.

In the picture you can see clinical photographs of a patient we treated at The VeinCare Centre. She had had a leg ulcer for over  2 years before we saw her. You can see the varicose veins affecting her leg calf, causing varicose eczema around the ankle and there is a small painful ulcer. 

She couldn’t get a referral to an NHS Vascular Service. She decided to pay for private treatment.

The ulcer was quickly healed by treating the superficial venous reflux by endovenous laser. The varicose veins have been eliminated and the varicose eczema is much improved. The skin is more healthy and now 6 years later, she has not had any more ulcers.

Leg-ulcer-treatment

When Is a Venous Leg Ulcer a Problem?

All leg ulcers are a problem because they cause pain, disability and social isolation. In younger people, they can lead to time off work and sometimes loss of employment.

All leg ulcers should be referred to a specialist team for assessment and treatment if they do not heal within 2 weeks.

How Can a Venous Leg Ulcer be Treated?

In the short term, a venous leg ulcer should be managed by a specialist team experienced in cleaning and dressing the ulcer and in this way, the ulcer can be healed by using compression, such as bandages or stockings. This specialist team may be attached to a GP surgery. Most GP surgeries have a “leg ulcer nurse” supported by healthcare assistants. 

In the longer term, the underlying vein problem should be identified by a Duplex Ultrasound Scan and if superficial venous reflux is found, it should be treated. 

Vein treatments for venous leg ulcers caused by superficial venous reflux can nowadays be carried out very safely under local anaesthetic as a walk in, walk out non-invasive procedure and the age of the person with a leg ulcer is no longer a barrier to effective treatment. Once an ulcer is healed and the underlying vein problem is addressed, under the guidance of a healthcare professional and provided there are no other health issues such arterial disease or diabetes, the risk of the ulcer returning can be reduced by wearing good quality medical-grade compression hosiery. 

Skin Grafting for Venous Leg Ulcers

Very occasionally, for the largest or very resistant ulcers a skin graft may be necessary. If your ulcer is due to varicose veins then these may be treated, usually once the ulcer has healed.

How long will it take the ulcer to heal?

It has usually taken many years for the venous disease to cause the ulcers, so it is not surprising that the ulcers may take a fairly long time to heal. Although most venous ulcers will heal in 3-4 months, a small proportion will take considerably longer.  Research in the UK published in 2019 has shown that treating Superficial Venous Reflux speeds up the time taken to get ulcers healed.

How can I stop the ulcer coming back?

Once your ulcer is healed, it does not mean that your problems are over. Although the skin is intact once the ulcer is healed, the area still remains vulnerable to injury. 

Good evidence exists to show that the risks of an ulcer coming back is reduced by treatment of the underlying vein condition. There is also some evidence that wearing compression stockings reduces ulcer recurrence. Even though you may have had treatment to your veins by Endovenous Laser or Sclerotherapy, you need to take precautions:

  • Wear compression stockings
  • Elevate your legs whenever possible.
  • Keep the skin in good condition by using plenty of moisturising cream to prevent dryness.
  • Weight loss, a healthy diet, exercise and stopping smoking are also vital to help heal your ulcer as well as for your general health.

Summary

  1. Venous leg ulcers are common, accounting for an estimated 80% of all leg ulcers and affecting up to 2% of the adult population.

  2. The condition can be extremely distressing for patients, greatly affecting their quality of life.

  3. There is evidence of considerable variation between National Health Service trusts as to which patients qualify for referral or treatment of varicose veins and leg ulcers.

  4. The 2013 NICE clinical guideline CG168 for the diagnosis and management of varicose veins recommends that patients with current ulceration should be referred to a vascular service for assessment and treatment within two weeks and that a venous duplex is performed to confirm the presence of superficial or deep venous reflux.

  5. The guidelines state that the first line of treatment should be vein treatment and that compression alone should only be used if this is not possible.

  6. A randomised controlled trial showed that treating vein problems speeds up the healing of an active ulcer.

  7. Compression stockings and vein treatments reduce the risk of ulcers coming back