Leg ulcers
Prevention & treatment

Venous and arterial leg ulcers

A leg ulcer occurs when skin breaks down, usually on the lower leg area, just above the ankle. Leg ulcers affect about 1 in 1000 people in Europe and are more frequent in elderly people: about 20 out of 1000 people are affected by the time they reach their eighties.

The majority of leg ulcers, about 80%, are caused by venous disease (venous leg ulcers), about 20% are of arterial (arterial leg ulcers) or mixed origin. If not treated correctly, a leg ulcer can become a chronic wound which requires longer healing time (sometimes more than 6 months), and they have a tendency to reoccur. 

What is a venous leg ulcer?

The cause of venous leg ulcers is venous insufficiency due to damage in the valves in the larger veins. Venous leg ulcers can be painless, but some are very painful. They can become infected. There is often an inflammation (dermatitis) around the venous leg ulcer.

Competent and well functioning valves are necessary for:

• Fractionating blood flow
• Ensuring one-way circulation
• Low blood pressure

When you valves are damaged:

• Blood accumulates in the lower legs 
• High blood pressure

This means that the veins or blood vessels by which the blood returns to the heart, are not functioning efficiently, which results in accumulation of the blood in peripheral blood vessels and increased pressure in lower leg veins. The consequence is fluid leackage from the veins beneath the skin. This results in swelling, thickening and damage to the skin. The damaged fragile skin may break down and form an ulcer. 

Risk factors:

People most at risk of developing venous leg ulcers are those who have previously had have a leg ulcer. Other risk factors are:

• Varicose veins
• Previous deep vein thrombosis in the affected leg
• Phlebitis in the affected leg
• Previous fracture, trauma, or surgery
• Family history of venous disease
• Symptoms of venous insufficiency: leg pain, heavy legs, aching, itching, swelling, skin breakdown, pigmentation and eczema

Prevention of venous leg ulcers:

If your patient is at risk, a few simple measures can help reduce the risk of developing a venous leg ulcer in several ways, such as wearing a compression stocking, losing weight and taking care of the skin.

• Compression stockings: If the patient is at risk of developing venous leg ulcers, or previously had a venous leg ulcer, you will probably prescribe compression stockings. These stockings are specially designed to steadily squeeze patient's legs, which improves circulation. They are usually tightest at the ankle and get gradually looser as they go further up the leg, ensuring blood flow upwards towards patient's heart. To be most effective, these stockings need to be worn at all times when patient is out of bed. 
• Losing weight: If your patient is overweight, losing weight can help prevent venous leg ulcers. Excess weight contributes to increased pressure in the veins in your legs, which can damage patient's skin. Venous ulcers are much more common among people who are obese than in people of normal weight. The combination of a balanced diet and regular moderate physical activity will help patient lose weight. Walking as often as possible is an excellent exercise avoiding long periods of sitting or standing and elevating legs whenever possible.
• Treating underlying problems: Venous disease manifests as varicose veins, one of the main causes of venous leg ulcers. They can be treated with various methods, all designed to remove the damage veins. Varicose veins can be treated using laser, by injecting the products which will close the affected veins, or by using a procedure where a catheter (a thin, flexible tube) is inserted into the affected veins, and high-frequency radio waves or lasers are used to seal them. Alternatively, your patient may need surgery to repair the damage to his/her leg veins or to remove the affected veins altogether.

Venous leg ulcer treatment:

If your patient has a venous leg ulcer, you will apply the wound management procedures with custom cleansing products and wounds dressings. It is very important to know that the treatment will only be successful if the compression bandages are worn as advised. This may be a perceived as a constraint, but the healing rates are considerably improved if the compression is maintained. Elevating legs and other preventive measures are very important to achieve rapid wound closure and to avoid re-occurrence of venous leg ulcers.

What is an arterial ulcer?

Arterial leg ulcers are caused by insufficient arterial blood flow to the lower extremities. The direct cause of reduced blood flow is vessel wall arteriosclerosis and atherosclerotic plaque accumulation causing vessel occlusion. Peripheral vascular disease associated with arterial insufficiency may result in limb tissue ischemia. In case this condition is prolonged, the skin on the leg becomes thin with loss of hair, subcutaneous tissue and muscles atrophy, nails become thickened, leg color and temperature change becoming pale and cool, pulses become difficult to palpate and pain increases with exercise or leg elevation.

The treatment of arterial leg ulcers requires a multidisciplinary approach. It is necessary to ensure a proper blood flow, which often involves surgical intervention. The patient must be encouraged to adopt and maintain healthy lifestyle changes which will help to improve tissue perfusion. 

Risk factors:

• Coronary heart disease
• History of stroke or transient ischemic attack
• Diabetes mellitus
• Peripheral arterial disease including intermittent claudication
• Obesity and immobility

Prevention of arterial ulcers:

The lifestyle changes that the patient can adopt will contribute to improve peripheral circulation and help prevent arterial leg ulcers.

• Stop smoking: Smoking severely reduces the tissue perfusion and is one of aggravating factors for arterial leg ulcers. 
• Healthy diet and weight loss: It Is important to reduce the intake of fat and to keep your cholesterol levels low. The patient should exercise as much as possible: this will help improve the blood circulation in your legs. If during exercising the patient feel some pain in his/her legs, it is normal. If the pain is more pronounced, or severe, it may be a sign that his/her arteries are seriously narrowed due to atherosclerosis. This needs to be addressed by a doctor.
• Take good care of patient's feet: Advice shoes which fit correctly and are not too small; Advice to keep feet warm avoiding feet and legs injuries; Examinate feet and legs daily for any changes in color or developing sores; Moisturizing the skin well to prevent skin damage which can develop ulcers.

These product & practice videos aim to update clinicians on best practices and explain how products can be used as preventing and managing infection in wound care can often be challenging. The series of videos was produced by Wounds International with the support of B. Braun.