Leg Ulcers

A leg ulcer is an open wound on the lower limb that fails to heal within the expected time. It can develop for several reasons, including venous disease, arterial disease, diabetes, pressure, inflammation, infection, trauma or malignancy. Finding the underlying cause is essential because treatment depends on the type of ulcer and the condition affecting the tissues. At The Whiteley Clinic, assessment combines clinical examination with vascular testing, including detailed Duplex ultrasound when venous disease is suspected.

What Is a Leg Ulcer?

An ulcer develops when the skin breaks down and fails to heal normally. These wounds can vary considerably in size, depth and appearance. Some cause significant pain, while others may cause little or no discomfort.

The appearance alone cannot reliably identify the underlying cause. A wound may look similar even when different vascular, metabolic or inflammatory conditions have caused it. Therefore, assessment needs to consider the patient's symptoms, medical history, circulation and the characteristics of the wound.

A persistent ulcer can also become infected. However, the presence of bacteria does not automatically mean that an ulcer has a clinical infection. NICE advises that antibiotics should only be used when clinical signs of infection are present.

What Are the Different Types of Leg Ulcers?

Leg ulcers can have different underlying causes. The main types include:

• Venous leg ulcers


• Arterial leg ulcers


• Diabetic foot ulcers


• Pressure ulcers


• Inflammatory or autoimmune ulcers


• Infectious ulcers


• Malignant ulcers


• Traumatic ulcers

What Causes a Leg Ulcer?

Several conditions can prevent normal wound healing. The main causes include:

• Venous disease, particularly chronic venous hypertension and venous reflux


• Peripheral arterial disease, which reduces blood supply to the tissues


• Diabetes, particularly when neuropathy, pressure or arterial disease affects healing


• Inflammatory and autoimmune conditions, including vasculitis


• Pressure or trauma


• Lymphatic disorders


• Infection


• Malignancy and other less common skin conditions

More than one factor can contribute to the same wound. For example, a person can have venous disease alongside peripheral arterial disease or diabetes. A thorough assessment therefore needs to identify all clinically relevant causes before treatment begins.

How Do Venous Ulcers Develop?

Venous ulcers develop when the veins cannot return blood effectively from the leg towards the heart. Venous reflux occurs when faulty valves allow blood to flow backwards. This can increase venous pressure in the lower leg and gradually damage the skin and underlying tissues.

The abnormal veins may be obvious varicose veins. However, problematic veins can also remain hidden beneath the skin. Reflux can involve superficial veins, perforating veins or the deep venous system. Venous obstruction can also contribute to chronic venous disease.

The resulting skin changes may include swelling, itching, eczema, pigmentation, induration and lipodermatosclerosis. Eventually, fragile skin can break down and form an ulcer.

The European Society for Vascular Surgery recommends full lower-limb venous Duplex ultrasound as the primary imaging method for suspected chronic venous disease and advises additional abdominal or pelvic venous assessment when supra-inguinal obstruction is suspected.

Common signs of venous disease

Early changes can appear before the skin breaks down. These may include:

• Ankle or lower-leg swelling


• Itching or venous eczema


• Brown or reddish skin pigmentation


• Hardening or tightening of the skin


• Lipodermatosclerosis


• Varicose veins


• Small visible veins around the ankle


• A wound that repeatedly heals and breaks down again

These changes should not be dismissed as purely cosmetic. NICE recommends referral to a vascular service for people with varicose veins associated with skin changes or a healed or unhealed ulcer below the knee.

What Are the Warning Signs Before an Ulcer Develops?

Recognising skin changes early can provide an opportunity to investigate the underlying vascular problem before an open wound develops.

Particular warning signs include persistent ankle swelling, new pigmentation, venous eczema, lipodermatosclerosis, skin induration and atrophie blanche, which appears as pale or white areas within chronically damaged skin.

Another sign is corona phlebectatica, a network of small blue or red veins around the ankle. The 2020 CEAP update recognises this as an advanced clinical sign of chronic venous disease.

A new wound, rapid deterioration, increasing pain, spreading redness, tissue necrosis or a change in the character of a longstanding ulcer requires prompt medical assessment.

How Are Venous Ulcers Classified Using CEAP?

The CEAP classification is an internationally recognised system for describing chronic venous disease. Venous ulcers are classified as C5 when healed and C6 when active. This classification helps describe the clinical stage of venous disease and distinguish between healed and active venous ulcers.

What Are Arterial Ulcers?

Arterial ulcers develop when inadequate arterial blood flow prevents tissues from receiving enough oxygen and nutrients.

Peripheral arterial disease can reduce blood flow to the foot and lower leg. Severe ischaemia can cause tissue loss, leg ulcer or gangrene and requires urgent vascular assessment.

Arterial wounds often develop on the toes, foot or pressure points. They may have a punched-out appearance and cause significant pain, particularly at rest or when the leg is elevated. The foot may also feel cold, while clinicians may find reduced pulses.

Assessment should include examination of the limb, palpation of foot pulses and measurement of the ankle-brachial pressure index (ABPI) or an equivalent vascular assessment. NICE recommends ABPI when clinicians assess peripheral arterial disease and warns that a normal ABPI alone should not exclude arterial disease in people with diabetes.

Clinicians should assess arterial circulation before applying strong compression because compression can be unsafe when significant arterial insufficiency is present.

What Are Diabetic Ulcers?

Diabetes can contribute to ulceration through several mechanisms. Peripheral neuropathy can reduce protective sensation, allowing pressure, friction or minor trauma to go unnoticed. Diabetes can also occur alongside peripheral arterial disease and infection, which can delay healing.

For this reason, clinicians should not automatically classify a diabetic foot or lower-limb leg ulcer as either venous or arterial. Instead, assessment should consider neuropathy, pressure, deformity, arterial circulation, infection and any coexisting venous disease.

A painless wound in a person with diabetes can still indicate significant tissue damage. Early specialist assessment is therefore important when a break in the skin develops.

What Other Conditions Can Cause Ulcers?

Not every chronic wound results from venous or arterial disease.

Other causes include inflammatory disorders such as vasculitis and pyoderma gangrenosum, connective tissue disease, lymphatic dysfunction, pressure, trauma and certain infections. Some ulcers can also result from skin cancer.

Marjolin’s ulcer is a rare form of skin cancer that can develop in a longstanding chronic wound or scar. It should be considered when an ulcer changes in appearance, becomes more painful or fails to heal as expected.

An ulcer that has an unusual appearance, occurs in an atypical location or fails to respond as expected needs further investigation. A biopsy may be appropriate when malignancy or another non-vascular diagnosis is suspected. Current specialist guidance also recommends reconsidering the diagnosis and investigating further when a presumed venous ulcer does not show an appropriate healing response.

How Is a Leg Ulcer Diagnosed at The Whiteley Clinic?

The first step is a detailed clinical assessment. This considers the ulcer itself, symptoms, skin changes, mobility, previous thrombosis, medical history and possible arterial or systemic causes.

Where venous disease is suspected, The Whiteley Clinic uses The Whiteley Protocol®, which includes a detailed Duplex ultrasound assessment performed by trained vascular technologists. The clinic's current diagnostic approach is designed to identify abnormal venous flow throughout the relevant venous systems, including superficial veins, deep veins and incompetent perforators.

Duplex ultrasound is particularly important because abnormal veins may not be visible on the skin. The scan can demonstrate venous reflux, obstruction and the anatomical veins involved. This information helps determine whether venous disease contributes to the ulcer and guides treatment planning.

When a more proximal venous obstruction is suspected, further imaging may be considered. Depending on the clinical findings, this can include assessment of the abdominal and pelvic veins or advanced imaging such as CT or MR venography.

Arterial assessment is also important when the clinical picture suggests reduced arterial circulation. This may include ABPI and, where indicated, arterial Duplex or other vascular imaging.

How Are Venous Ulcers Treated?

Treatment depends on the underlying cause identified during assessment.

For venous disease, clinicians use wound care and appropriate compression as important parts of management. However, compression does not correct venous reflux itself. When superficial venous reflux contributes to an active leg ulcer, treating the abnormal veins can address an important underlying cause.

Clinicians may use endovenous treatments such as endovenous laser ablation (EVLA) or radiofrequency ablation when appropriate. Ultrasound-guided foam sclerotherapy and other procedures can also treat selected abnormal veins.

The EVRA randomised trial found that early endovenous treatment of superficial venous reflux, alongside compression and wound care, accelerated leg ulcer healing compared with deferred treatment.

Leg Ulcer Treatment Revolution – by Prof Mark S Whiteley

At The Whiteley Clinic, treatment planning follows the findings of the individual vascular assessment. The clinic describes its approach as identifying and treating the underlying venous abnormalities rather than treating the wound alone. Depending on the findings, treatment may include EVLA, treatment of incompetent perforators using TRLOP, foam sclerotherapy or other appropriate venous procedures.

What Happens When an Ulcer Is Not Healing?

When a leg ulcer does not improve as expected, clinicians should reassess the wound rather than continue the same treatment indefinitely.

Clinicians may need to review the diagnosis because venous reflux, arterial insufficiency, infection, pressure, neuropathy, inflammatory disease or malignancy may have been missed or may have developed alongside the original condition.

NICE advises that most ulcers contain bacteria but do not have a clinical infection. Antibiotics should therefore not be used simply because bacteria are present. Signs such as spreading redness or swelling, local warmth, increasing pain or fever may indicate infection and require appropriate assessment.

When Should a Leg Ulcer Be Assessed?

Early assessment is particularly important when there is:

• A wound below the knee that does not heal as expected


• Recurrent ulceration


• New ankle swelling or skin discolouration


• Venous eczema or lipodermatosclerosis


• Varicose veins with skin changes


• Reduced foot pulses or symptoms of arterial disease


• Diabetes with a new break in the skin


• Increasing pain, redness, warmth or discharge


• Tissue that becomes black, pale or rapidly deteriorates


• An unusual or longstanding wound with a change in appearance

A sudden deterioration, severe ischaemic pain, spreading infection, systemic illness or suspected tissue necrosis requires urgent medical attention.

An accurate diagnosis provides the basis for effective leg ulcer treatment. Identifying whether the wound has a venous, arterial, diabetic, inflammatory, infectious or other cause allows clinicians to target the condition preventing normal healing.