Venous Ulcer

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. Venous disease is the main reason for over two thirds 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. If you see Mr Braithwaite, he will examine you and do some tests to see what sort of ulcer you have. 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 tubes 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 (see varicose veins) or can be damaged by thrombosis (clots) in the veins (see DVT). If the valves are 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.

4. How will I be treated?
Treatment of a venous leg ulcer is aimed firstly at controlling the high pressure in the leg veins and secondly at the ulcer itself (O’Meara et al. 4 layer bandage compared with short stretch bandage for leg ulcers: systematic review and meta-analysis. BMJ 2009;338:1054-1057). The mainstays of treatment are compression bandaging or stockings and elevation of the limb:

Elevation of the limb. The higher the leg, the lower the pressure in the leg veins! If the foot is elevated above the heart then the pressure in the foot drops to a normal level. Put your legs up whenever you can and as high as you are able-the arm of the sofa is good. Elevate the lower end of your bed (6 inches or so) so that when in bed your feet are a little higher than your head. You can use some old books for this.

Compression bandaging or stockings. In order to keep the pressure in the leg veins at the ankle low when you are standing up, 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”. If you have difficulty putting on your stockings then you can buy a special stocking applicator. Mr Braithwaite will discuss these treatments with you.

Dressings. The nurse will use a number of different dressings under the bandages depending on the state of the ulcer itself. These dressings may well change as the ulcer progresses

Recent Evidence has shown that a simple non-adherent dressing is all that is required. There is no evidence that ‘fancy’ dressings containing special properties are any better. (Don’t waste money when dressing leg ulcers. Sultan and McCollum. Br J Surg 2009;96:1009-1100)

Surgery. If your ulcer is due to varicose veins then these may be treated.

5. 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 tome to heal. Although most venous ulcers will heal up in 3-4 months, a small proportion will take considerably longer. Don’t despair! Even in these resistant cases treatment is eventually successful.

6. 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 the underlying problem with the veins remains and 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.
Keep the skin in good condition by using plenty of moisturising cream to prevent dryness.
Weight loss, fresh fruit, exercise and stopping smoking are also vital to help heal your ulcer as well as for your general health.

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