About Leg Ulcers
1. What is a leg ulcer?
A leg ulcer is simply a break in the skin of the leg. The immediate cause is usually an injury, often a minor one that breaks the skin. In most people such an injury will heal up without difficulty within a week or two. However, if there is an underlying problem the skin does not heal and the area of breakdown may even increase in size. This is a chronic leg ulcer.
2. What causes leg ulcers?
The most common underlying problem causing chronic leg ulcers is disease of the veins of the leg. Often this is a simple varicose vein problem, hence the term "varicose ulcer", that can be easily treated without surgery. Venous disease is the main reason for about three quarters of all leg ulcers. There are less common causes for leg ulcers such as disease of the arteries, diabetes or rheumatoid arthritis as well as a number of even rarer conditions. In some cases two or more conditions may be causing damage at the same time. Oedema (swelling), cellulitis (inflammation) and immobility often aggravate the situation.
This is why it is essential that you are seen by a vascular specialist who will be able to confirm the cause of the ulcer by performing a duplex ultrasound scan of the veins and sometimes the arteries as well as measure ankle blood pressure (ankle Doppler pressures) to assess blood flow. EVERYONE with a leg ulcer should be referred to a specialist and undergo these tests.
The following advice applies to venous ulcers and may not be appropriate for other sorts of ulcers:
3. How does venous disease cause ulcers?
The veins in your leg are vessels that carry the blood back from the foot towards your heart. The legs contain one-way valves that should allow flow up the leg and not back down the leg. However, these valves are not very effective in some people or can be damaged by thrombosis (clots) in the veins. If the valves are damaged, blood can flow the wrong way down the veins, which results in a very high pressure in the veins towards the ankle when standing up. This abnormally high pressure in the veins damages the skin and leads to skin changes and ulcers. Often severe varicose skin changes develop in the lower inner leg (gaiter area) before ulceration occurs. These skin changes are manifest by a combination of darkening or pigmentation of the skin, eczema, soft tissue hardening and inflammation (lipodermatosclerosis).
4. How will I be treated?
Once the diagnosis has been confirmed, the mainstays of treatment of venous leg ulcers are compression bandaging or stockings and treatment of the underlying vein problem if possible. In addition, you will need appropriate local dressings and skin care to protect the surrounding skin.
Compression bandaging or stockings. In order to reduce the pressure in the leg veins at the ankle when you are standing up as well as reduce any swelling (oedema), you will be treated with compression bandaging or stockings. Several layers of bandages may be required to get the necessary pressure to control the veins. Once the ulcer is healed, compression stockings are usually necessary to prevent the ulcer from returning. These stockings need to be specially fitted and are much stronger than ordinary "support tights". Usually, Class 2 knee length stockings are advised. They should be worn during the day and renewed every three months. It must be borne in mind that these stocking are very tight and some people will struggle to get them on and off without assistance.
Dressings. Simple non-adherent dressing (NA) are often best in order to prevent an allergy developing due to continuous use of more elaborate dressings. Practice and District nurses may try different types of dressing particularly if the ulcer is very wet but care must be taken to observe for hypersensitivity in the surrounding skin (allergic reaction) as this is a common problem with indiscriminate use of "active" dressings.
Skin care. The skin around the ulcer is often dry. It is important to keep it in good condition using moisturising agents such as Doublebase or Diprobase.
Treatment of underlying varicose veins. The majority of people with chronic venous ulcers will have an underlying varicose vein problem that can be easily treated by one of the minimally invasive methods (e.g. Foam, Endothermal Ablation or ClariVein) well described elsewhere in this website. In our recent study of venous ulcers, we have shown an 88% ulcer healing rate after Ultrasound-guided Foam Sclerotherapy treatment. Recently, a major national clinical trial published in the New England Journal of Medicine has confirmed that early treatment of superficial venous reflux improves leg ulcer healing and that patients recover quicker.
5. How long will it take the ulcer to heal?
The majority of venous ulcers will completely heal within a matter of weeks after treatment although a small proportion will take considerably longer. It has usually taken many years for the venous disease to cause the ulcers, so it is not surprising that some ulcers may take a fairly long tome to heal. Don't despair! Even in these resistant cases treatment is eventually successful in most cases. For the largest or very resistant ulcers a skin graft may be necessary.
6. How can I stop the ulcer coming back?
Once your ulcer is healed the risk of it recurring is very much reduced if it has been possible to correct the underlying varicose vein problem. If not, and the underlying problem with the veins remains you must take precautions to prevent the ulcer recurring:- wear compression stockings (or bandages in a few severe cases) at all times during the day, elevation of the legs whenever possible to reduce swelling, keep the skin in good condition by using plenty of moisturising cream to prevent dryness, weight loss, fresh fruit (Vitamin C), exercise and stopping smoking are also vital to help heal your ulcer and keep it healed as well as for your general health.
The image on the left shows severe varicose skin changes in the lower leg associated with very large varicose veins. This situation often precedes the development of a varicose leg ulcer. Correction of the underlying veins usually results in healing of the ulcer.
The image below shows Foam Sclerotherapy treatment in a patient with severe varicose skin changes.