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LEG ULCERS

A leg ulcer - a break in the skin on the lower leg that takes more than 6 weeks to heal - is commonly the result of vascular insufficiency: chronic venous hypertension (a venous ulcer, the most common) or of poor arterial blood supply (an arterial ulcer). Because arterial and venous leg ulcers need different management - compression therapy is dangerous for patients with arterial disease - an important part of leg ulcer assessment is to assess arterial sufficiency by calculating the ankle brachial pressure index (ABPI). ABPI = highest ankle systolic pressure/highest brachial systolic pressure A hand-held Doppler device and a sphygmomanometer and cuff are used to compare ankle and brachial systolic blood pressure.

VENOUS ULCER

Risk factors

  • Deep vein thrombosis
  • Thrombophlebitis
  • Oedematous legs
  • Multiple pregnancies
  • Varicose veins
  • Previous leg ulceration.

Presentation

  • Generally in gaiter area
  • Exuding, shallow ulcer with diffuse edge
  • Associated with some pain

Staining (pigmentation) of the skin, induration (hardening, ‘woody’ feel), varicose eczema and oedema.

  • Atrophie blanche (areas of white skin stippled with red dots)
  • ABPI >0.8 on Doppler assessment.

Management aims

  • Reduce oedema and pressure in superficial venous system.
  • Aid venous return by increasing velocity of flow in deep veins.
  • Treat wound according to findings of wound bed.

Venous leg ulcers Patient UK https://www.patient.co.uk/doctor/venous-leg-ulcers-pro

SIGN 120. Management of chronic venous leg ulcers, 2010. https://www.sign.ac.uk/guidelines/fulltext/120/

ARTERIAL ULCER

Risk factors

  • Ischaemic heart disease
  • Hypertension
  • Angina
  • Diabetes mellitus
  • Intermittent claudication
  • Transient ischemic attack
  • Myocardial infarction
  • Rheumatoid arthritis.

Presentation

  • Ulcer generally below ankle
  • Dry, deep wound, with 'cliff type' edge
  • Dusky-coloured, cold foot
  • Pain in lower legs/foot when raised
  • Loss of hair on legs
  • Atrophic shiny skin on shin
  • Thickened toe nails
  • Loss of pedal pulses 
  • ABPI <0.6.

Management aims

  • Treat symptoms.
  • Treat wound according to assessment of wound bed.
  • Reduce the risk of infection.
  • If ABPI <0.5, urgent referral to vascular surgeon recommended.

MIXED ULCER (elements of venous and arterial disease)

Presentation

  • Venous problems and arterial insufficiency
  • ABPI 0.6-0.8 on Doppler assessment

Management aims

  • Reduce symptoms
  • Treat wound according to assessment of wound bed.

LEG ULCER REFERRAL INDICATIONS

Before treatment

  • Uncertain diagnosis.
  • Suspected alternative (non-venous) cause of ulceration:

- arterial or mixed venous/arterial ulcer. Refer for assessment of arterial disease if ABPI <0.8, urgently to vascular surgeon if ABPI <0.5

- ulcer malignant or deteriorating rapidly. Ulcers of atypical appearence or distribution may require biopsy by a dermatologist

- rheumatoid ulcer, or ulcers associated with systemic vasculitis

- diabetic ulcer or newly diagnosed diabetes in a person with an ulcer

During treatment 

  • Complication related to the ulcer or treatment:

- contact dermatitis (refer to a dermatologist for patch testing).

- cellulitis requiring intravenous antibiotics or worsening with treatment.

- uncontrolled pain (refer to specialist pain team).

  • Ulcer unhealed or worsening ulcer after 2–3 months of standard treatment.
  • Recurring ulcers.
  • Conditions needing specialist intervention, e.g. varicose veins, arterial insufficiency.

Practice Nurse featured article

The art – and science – of wound healing  Sylvie Hampton

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