Leg ulcers may be defined as a breakdown of epidermal and dermal tissue below the knee or on the leg or foot, due to any cause, that are slow to heal. They remain a major problem to both the sufferer and to the health service. The management of patients with leg ulcers can be time-consuming and often long-term.
It is estimated that approximately 1.5% of the adult population in the UK is affected by active leg or foot ulceration which equates to 730,000 patients.* People with leg wounds often only seek clinical advice when healing is delayed or where there are risk factors for non-healing and it is recommended that they should ideally receive assessment within 14 days of presentation. Generally, the sooner they are assessed, and the appropriate treatment plan implemented, the quicker the healing process. Venous ulcers are far more common than arterial ulcers. Uncomplicated venous ulcers tend to be managed in the community whereas people with arterial ulceration may require further investigation by a specialist.
Accurate assessment of patients with an ulceration is a highly complex skill and underpinning the process is a good knowledge of the anatomy and physiology of the lower limb and circulatory system. Assessment requires an understanding of the theories around how an ulcer develops, an awareness of the causes of ulceration and the ability to gather the appropriate information to determine the type of ulceration and to identify the wider factors that are likely to delay healing. For this reason, an appropriately qualified clinician should carry out this assessment before initiating a treatment plan.
Causes of Venous Leg Ulcers
A venous leg ulcer can develop after a minor injury to the limb. If an assessment shows that there is a problem with the circulation of blood in the veins of the legs, healing of the wound may be delayed. In healthy legs, the return of the blood to the heart through the veins is usually good as the muscle activity helps to push blood along. As we become older, the blood moves less well and collects in the lower legs, causing swelling. Sometimes varicose veins develop where the walls of the veins are weak and are unable to hold a high pressure of blood. This is known as venous insufficiency or venous hypertension. Other factors which may affect blood flow are obesity, lack of mobility and conditions such as a deep vein thrombosis or phlebitis which damage the valves inside the veins.
Venous Leg Ulcer Characteristics
A venous leg ulcer often develops on the inner side of the leg, just above the ankle area although they can appear anywhere on the lower leg, above the ankle and below the knee. The ulcers tend to be quite shallow, but the surface area can be large and irregularly shaped. They can be very wet, oozing discharge, which may be offensive smelling. The ulcer can be painful and may itch. Often the limb is swollen and there could be discoloured or hardened skin around the ulcer. Where venous leg ulcers are present, there can sometimes be associated skin conditions which can prove to be as problematic as the ulcer itself to heal. These may include varicose eczema, dermatitis, hyperkeratosis, cellulitis or lipodermatosclerosis (a ‘woody’ hardened feeling to the skin). These skin conditions must be managed well in addition to the ulcerated area to completely heal the limb. The use of medicated bandages and/or topical steroid creams and antibiotics may assist with healing when used under compression therapy.