Leg Ulcer

Vascular Disorders of the lower‐Extremity 2011
“Leg Ulcer”
Leg ulcers
Leg ulcers refer to full thickness skin loss on the leg or foot due to any cause.
They occur in association with a range of disease processes, most commonly
with blood circulation diseases. Leg ulcers may be acute or chronic. Acute ulcers
are sometimes defined as those that follow the normal phases of healing; they
are expected to show signs of healing in less than 4 weeks and include traumatic
and postoperative wounds. Chronic ulcers are those that persist for longer than 4
weeks and are often of complex poorly understood origin.
Ulcers may be provoked by injury or pressure such as from a plaster cast or ill-
fitting ski boot. They may also be caused by bacterial infection, especially
impetigo, ecthyma and cellulitis and less often tropical ulcer, tuberculosis or
leprosy.
Chronic leg ulceration affects about 1% of the middle-aged and elderly

population. It most commonly occurs after a minor injury in association with:
• Chronic venous insufficiency (45-80%)

• Chronic arterial insufficiency (5-20%)
• Diabetes (15-25%)
Chronic leg ulcers may also be due to skin cancer, which may be diagnosed by a
skin biopsy of the edge of a suspicious lesion. There are also many less common
causes of ulcers including systemic diseases such as systemic sclerosis,
vasculitis and various skin conditions especially pyoderma gangrenosum.
Venous insufficiency refers to improper functioning of the one-way valves in the

veins. Veins drain blood from the feet and lower legs uphill to the heart. Two
mechanisms assist this uphill flow,
Dr. Bhuiyan Ma yousuf, MBBS, MSc ( Sweden), D.D ( Singapore), PGCD ( Karolinska
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“Leg Ulcer”
1. the calf muscle pump which pushes blood towards the heart during
exercise, and
2. the one-way valves which prevent the flow of blood back downhill.
There may be reflux through the valves, obstruction of the veins and/or impaired
calf pumping action result in pooling of blood around the lower part of the leg to
just below the ankle. The increased venous pressure causes fibrin deposits
around the capillaries, which then act as a barrier to the flow of oxygen and
nutrients to muscle and skin tissue. The death of tissue cells leads to the
ulceration.
Arterial insufficiency refers to poor blood circulation to the lower leg and foot and
is most often due to atherosclerosis. In atherosclerosis the arteries become
narrowed from deposits of fatty substances in the arterial vessel walls, often due
to high levels of circulating cholesterol and aggravated by smoking and high
blood pressure (hypertension). The arteries fail to deliver oxygen and nutrients to
the leg and foot resulting in tissue breakdown.
Diabetic ulcers are caused by the combination of arterial blockage and nerve
damage. Although diabetic ulcers may occur on other parts of the body they are
more common on the foot. The nerve damage or sensory neuropathy reduces
awareness of pressure, heat or injury. Rubbing and pressure on the foot goes
unnoticed and causes damage to the skin and subsequent ‘neuropathic’
ulceration.
Causes of leg ulcers:
Leg ulcers may be caused by:
• Poor circulation, often caused by arteriosclerosis
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• Venous insufficiency (a failure of the valves in the veins of the leg that causes
congestion and slowing of blood circulation in the veins)
• Other disorders of clotting and circulation that may or may not be related to
atherosclerosis
• Diabetes
• Renal (kidney) failure
• Hypertension (treated or untreated)
• Lymphedema (a buildup of fluid that causes swelling in the legs or feet)
• Inflammatory diseases including vasculitis, lupus, scleroderma or other
rheumatological conditions
• Other medical conditions such as high cholesterol, heart disease, high blood
pressure, sickle cell anemia, bowel disorders
• History of smoking (either current or past)
• Pressure caused by lying in one position for too long
• Genetics (they may be hereditary)
• A malignancy (tumor or cancerous mass)
Diabetic ulcers are more likely if diabetes is not well controlled by diet and/or medication. Ulcers
are also more likely if there is poor care of the feet, badly fitting shoes and continued smoking.
trigger or worsen arterial leg ulcers:
• Smoking.
• High blood pressure.
• Diabetes.
• Arthritis (rheumatoid arthritis).
• Old leg ulcers.
• Coronary heart disease, including coronary thrombosis (blood clots in the
arteries of the heart).
• Atherosclerosis in the legs.
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Diagnosis/Assessment of leg ulcer:
Accurate assessment is the key to effective ulcer treatment. Comprehensive

assessment identifies ulcer aetiology and factors, which may delay healing.
Assessment consists of:
1. Medical history
2. Physical examination
3. Ulcer examination (site, size, presentation)
4. Clinical investigations
• Blood pressure, weight, urinalysis
• Ankle brachial pressure index (ABPI) using Doppler probe
• Investigations to exclude other causes
5. Wound measurement
6. Identifying hard-to-heal ulcers using "rule of six"
Medical History
Although most ulcers fall into the category of venous (81%), arterial (10%) or
mixed arterial/venous (7%), other causes such as diabetes, rheumatoid arthritis
or malignancy may be responsible. History taking should record any aspects of
past medical history which may suggest venous disease or non-venous disease,
such as previous cardiac surgery, diabetes, and rheumatoid arthritis (see Table 1
below).
Ulcer history to be recorded may include: previous history of leg ulcers, sites of
previous ulcers, number of recurrences and past treatment methods.
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Table 1. Past Medical History Suggestive of Venous or Non-venous Disease
Arterial ulcers ;BDR-CROSH

Venous ulcers :VSF-BOSS-PASID
• Varicose veins
• Diabetes
• History of leg swelling
• Smoking
• History of blood clots in deep veins,
• High blood fat/cholesterol
i.e. deep vein thrombosis (DVT)
• High blood pressure
causing post-thrombotic syndrome
• Renal failure
(in 5% of cases)
• Obesity
• Sitting or standing for long periods
• Rheumatoid arthritis
• High blood pressure
• Clotting and circulation
• Multiple pregnancies
disorders
• Previous surgery
• History of heart disease,
• Fractures or injuries
cerebrovascular disease or
• Obesity
peripheral vascular disease
• Increasing age and immobility
Physical Examination: Diagnostic feature of various types of ulcers:
It is important that both legs are examined lying and standing. Reduced ankle
joint movement is associated with slower healing rates. General signs and
symptoms of venous, arterial and mixed arterial/venous are outlined in Table 2
below.
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Table 2. Signs and Symptoms of Leg Ulcers:
contents Venous Arterial

shape Irregular shaped ulcer Regular shaped ulcer with
‘punched out’ appearance
pain Fairly painless unless infected Usually painful
site Typically affects the gaiter area of Typically affects the
the leg (between knee and ankle) pressure areas like the
foot
swelling Swelling of the limb usually Swelling of the limb not
present always present
Temp. Limb is warm Limb is cold
pulse Pulses on the leg may be Pulses on the leg are
diminished but are present usually absent
color Pigmentation (brown staining of white or bluish, shiny.
skin)
eczema Stasis Eczema usually presents Eczema absent
depth Shallow in appearance Deep ulcers with sloughy

Granulation tissue evident base; tendon or bone
may be visible
SPSS-C-DEPT
Mixed Arterial/Venous
These will have signs and symptoms associated with both
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“Leg Ulcer”
contents Venous Arterial

shape Irregular shaped ulcer Regular shaped ulcer with
‘punched out’ appearance
pain Fairly painless unless infected Usually painful
site Typically affects the gaiter area of Typically affects the
the leg (between knee and ankle) pressure areas like the
foot
swelling Swelling of the limb usually Swelling of the limb not
present always present
Temp. Limb is warm Limb is cold
pulse Pulses on the leg may be Pulses on the leg are
diminished but are present usually absent
venous and arterial disease.
Ulcer Examination
Assessment of the site, size and presentation of the ulcer is very important. The
condition of the ulcer base and the surrounding skin will determine treatment.
Table 3. Ulcer Examination
Venous Arterial
Site Gaiter region, lateral or Anywhere on leg,
medial malleolus especially toes, feet or
heel
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Venous Arterial
Size Varying size - Size may Small punched out ulcers
vary from small to full
circumference of the leg
Presentation Shallow in appearance Deep ulcers with sloughy

Granulation tissue base; tendon or bone
evident may be visible
Assessment of Ulcer: Using Wound Bed Preparation Acronym TIME
The concept of TIME incorporates the pathophysiology of chronic wounds such

as leg ulcers.
• T is for Tissue: non-viable tissue in the wound delays healing through

providing a focus for infection and impeding wound closure.
• I is for Infection: a continued inflammatory response leads to sustained
high levels of inflammatory cytokines and proteases, along with
diminished growth factor activity.
• M is for Moisture: chronic wound fluid is biochemically distinct from acute
wound fluid and contains components, which interfere with wound healing.
• E is for Edge of wound, advancing or non advancing: healthy or not; non-
responsive wound cells and excessive protease activity prevent migration
of the epidermal margin.
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Wound Bed Preparation is the management of the wound to accelerate

endogenous healing or to facilitate the effectiveness of other therapeutic
measures.
Tissue - Remove non-viable or deficient tissue - may be episodic or continuous
• Necrotic Tissue: Sharp surgical debridement if adequate arterial supply -

alternatively autolytic methods
• Sloughy Tissue: Autolytic, enzymatic, mechanical or biological
debridement
Moisture imbalance - Correct desiccation and avoid maceration
• Intervention: Rehydrate/debride (Revisit T)

• Address Cause: Control oedema by appropriate means. Use moisture
balance dressings (e.g. foams, alginates, hydrofibres)
Infection or inflammation - Diagnose and treat infection or inflammatory diseases
• Infection - Diagnosis of infection can be difficult. The interpretation of swab

results needs to be done with care and always consider clinical features.
Management of infection may require intravenous or oral therapy.
Consider the use of modern topical anti-microbials. If infection is not
resolving after 2 weeks of therapy, consider referral or seek advice.
• Inflammation - Consider inflammatory diseases in ulcers that have
unusual presentations/appearances and are not responding to first line
treatment. Confirmation of diagnosis may require specific blood tests,
biopsy or if in doubt, consider referral.
Edge - Consider surgical intervention or advanced therapies if edge is not

advancing and T, I & M have been addressed.
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• Intervention: Surgical debridement

• Intervention: Reassessment. Consider biological agents, advanced
therapies or skin grafting.
Selection and interventions will be based on clinician's knowledge, skills,

resources, patient choice and cost-effectiveness.
Identifying the Hard to Heal Ulcer
Accurate assessment of venous leg ulcers needs to identify patients with ulcers
which may be slow to heal so individual treatment may be planned to accelerate
the rate of healing. It is appropriate to refer these patients for further vascular
assessment. To identify "slow healers" the "Rule of Six" may be employed; this
rule states that venous ulcers larger than six centimetres squared, present for six
months or more when treated with compression are unlikely to heal within six
months.
Rule of Six
Ulcer >6cm2 in size
Ulcer present for >6 months
Unlikely to heal with compression in six months
Clinical Investigations
Blood pressure,
weight,
urinalysis
Doppler ankle brachial pressure index (ABPI) measurements should be
recorded in all patients.
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“Leg Ulcer”
Additional testing to check for other conditions that can be related to a skin ulcer
includes:
• A complete blood count (CBC), to check for blood disorders, such as

thalassemia.
• A fasting blood glucose test, to check for diabetes, a common cause of
neuropathic ulcers and poor wound healing in general.
• An erythrocyte sedimentation rate (ESR), to check for signs of autoimmune
disease, such as rheumatoid arthritis, which can cause venous inflammation and
lead to skin ulcers.
If you have a venous skin ulcer that has not healed after a few weeks of wearing
compression stockings and elevating your legs, your doctor may do a:
• Tissue culture, to check for a bacterial or fungal infection.
Skin biopsy, to check for cancer. Although it is rare, there is an increased risk of
squamous cell carcinoma with chronic skin wounds.The absence of pedal pulses may
indicate arterial insufficiency; however, palpation alone is inadequate
assessment.
Doppler ABPI is an objective assessment in identifying arterial disease and

should be carried out by staff trained in the area.
Procedure for ABPI Measurement
• Patient should be supine and resting in warm room for 10-15 minutes.
• The procedure should be explained to the patient.
• A blood pressure cuff is placed around the upper arm and the brachial
artery insonated with a Doppler probe.
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• The cuff is inflated until the arterial signal disappears and is slowly
deflated. The pressure at which the arterial signal returns is the systolic
pressure.
• The procedure is repeated on the other arm.
• A cuff is placed on the lower leg above the ankle protecting the ulcer site.
• The dorsalis pedis and posterior tibial arteries are insonated and the
systolic pressure recorded for both arteries, as for the arm.
The ABPI is calculated by dividing the highest ankle pressure by the higher of the
two arm pressures.
ABPI =
A=Highest ankle systolic pressure

B = Highest brachial systolic pressure
Caution!
• ABPI measurements in patients with diabetes and/or atherosclerosis may

not be reliable. Patients with these conditions may have falsely high
readings due to calcification of the vessels or atherosclerosis.
Significance of ABPI Results
>1.3 Suggest non compressible calcified artery

0.92 - 1.3 Normal
0.5 - 0.92 Mild/Moderate claudication
0.35 - 0.50 Severe claudication
<0.35 Critical ischaemia
1. ABPI of between 0.92 and 1.30: are considered normal
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Vasccular Disorderss of the llower‐Extremitty 2011
1
“Leeg Ulcerr”
2. ABPI of greater tha

an 1.30: su
uggests a non-comprressible calcified arterry
and is no
ot an accura
ate reflectio
on of arteria
al function (e.g.
( diabettes).
3. ABPI of between
b 0.5 and 0.92: mild or inttermittent claudication.
**It is us
sually considered safe
e to apply graduated
g c
compressio
on bandage
es
on patients with venous leg ulcers witth an ABP
PI of greate
er than 0.8
8.
Howeverr, if patientss cannot tollerate the compressio
c n there may be greate
er
arterial disease
d than
n the ABPI indicates and
a the pattient require
es referral to
t
a vascula
ar clinic for further inve
estigations..
4. .35 - .5 in
ndication se
ever claudiccation
5. ABPI bettween 0.00
0 and 0.35: indicates severe
s periipheral arte
erial diseasse
and requ
uires urgen
nt referral to
t a specia
alist vascu
ular clinic. Any
A type of
o
compres
ssion treatm
ment is conttraindicated
d in these patients.
** Ulcer aetiolog
gy may be mixed if symptoms of venous dissease are also
a present.
Mixe
ed venous arterial
a ulce
ers with an ABPI of be
etween 0.5––0.8, may, with carefu
ul
supe
ervision, be
e treated with
w reduced compresssion of 15
5–25 mmHg
g. However,
comp
pression bandaging
b can furthe
er comprom
mise arterial blood supply,
s and
shou
uld be avoid
ded until aftter specialisst vascular assessmen
nt.
Notes:
• regarding calculation of
o ABPI (2):
o oc
ccasionally brachial blood pressures are averaged and/or the brachial pressure is
on
nly measured
d in one arm; usually the right.
r Note tho
ough that a pressure
p diffe
erence
be
etween the rig
ght and left brachial
b arterie
es of at least 20 mmHg is present in 3.5
5% of
th
he normal hea
althy populatiion and over 20% of patie
ents with PAD
D and thereforre the
prressure should be measured in both arms (as the higher
h of the two pressure
es will
most
m closely re
eflect central aortic pressure)
o it is possible for patients with PAD to
t have bila
ateral subclavvian-axillary artery
Dr. Bhuiyan
B Ma yousuf,
y MBBS, MSc ( Sweden),
S D.D
D ( Singaporre), PGCD ( Karolinska
Intituute).
“Leg Ulcer”
occlusive disease and in this situation both brachial pressures will be artificially low
and the ABPI artificially elevated
o if individual calf vessels are heavily diseased or occluded while a single tibial vessel
is relatively preserved, the ABPI would fail to indicate the fact that part of the calf
may be significantly underperfused and, therefore, more susceptible to pressure
damage
a difference of >10 mmHg between systolic pressure readings taken from
different pedal vessels should alert the clinician to this possibility
o calcified and incompressible crural vessels may result in a spuriously elevated ABPI
(as the arterial wall becomes stiffer and resists compression, giving a falsely high
ankle systolic pressure)
with respect to diabetics, an ABPI > 1.30 has been suggested as a strong
indicator of calcification (4)
measurement of great toe artery pressure for calculation of toe brachial
index (TBI) is commonly advocated in diabetic patients because of the
increased prevalence of calcification in the crural vessels
• there is evidence from several large longitudinal studies that a low ABPI, usually taken as
<0.8 or <0.9, is associated with a marked increase in cardiovascular events, recurrent events
and mortality, whether lower limb symptoms are present or not (2)
• the Edinburgh Artery Study has shown that even a near-normal ABPI (0.91–1.0) is
associated with reduced 5 year survival (3)
• a further study showed that, compared with an ABPI >or=1.1, the risk of death increased
linearly in the lower ABPI categories: ABPI 0.7-0.89, hazard ratio (HR) 1.7 (1.2-2.4,
P<0.001); ABPI<0.5, HR 3.6 (2.4-5.4, P<0.001) (6)
• in patients with chronic venous ulceration, it is currently recommended that the ABPI should
be >0.8 if compression bandaging is to be applied safely in the community (2
Management/Treatment/Secondary Prevention
1. Cleansing and debridement

2. Appropriate dressing choice
3. Wound bed preparation
4. Appropriate use of topical antimicrobials
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5. Compression therapy
• Below-knee graduated multi layer compression
• Reduced compression
• Compression stockings
• Intermittent pneumatic compression
6. Surgery (e.g., varicose vein surgery, subfascial endoscopic perforator
surgery, skin grafting)
7. Appropriate management of associated complications (e.g., oedema,
infection, dermatitis, allergic contact dermatitis)
8. Referral to vascular or other disease-specific specialist
9. Patient/family education
10. Follow-up with reassessment
Venous Leg Ulcers: Treatment
Cleansing
Cleansing of the ulcer should be kept simple and take the form of irrigation with
warmed tap water or saline.
Best practice is to soak the affected leg(s) in a bucket of warm water lined with a
plastic bag. This facilitates the removal of wound debris and de-scaling of dry
skin. In clinical practice the use of an emollient, such as Hydromol™ or
Oilatum™, may be added to the warm water to help moisturise the leg and
facilitate the removal of dry scaly skin. Occasionally Potassium Permanganate
may be used.
Appropriate Dressing Choice
A clean dressing technique is acceptable for chronic leg ulcers and should be
aimed at preventing cross-infection, strict asepsis is unnecessary.
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The emphasis of dressing choice is placed on allergen avoidance and based on

simple nonadherent dressings that do not cause damage to the wound bed.
Patients with leg ulcers are prone to contact sensitivity particularly from wool,
alcohols and rubber mixes. Dressings containing these products should be
avoided in clinical practice. Products containing lanolin and topical antibiotics
should also be avoided.
In uncomplicated ulcers, simple non-adherent dressings are

recommended as no specific dressing has been shown to improve healing
rates.
In exuding ulcers, it may be appropriate to choose an absorbent dressing
to help reduce dressing changes (e.g. foam/alginate dressings).
In painful ulcers, a hydrocolloid or foam dressing is appropriate.
In malodorous wounds: there are a variety of dressings that can help
eliminate odour and absorb exudate including charcoal dressings and
alginate dressings. Consider the use of antimicrobial dressings such as,
Cadexomer Iodine dressings (Iodoflex) and dressings impregnated with
silver (e.g. Acticoat, Acticoat Absorbent).
In macerated wounds: avoid hydrocolloids and film dressings. Choose
absorbent dressings such as foams (e.g. Allevyn foam). Select an
appropriately sized dressing (5 cm larger than the wound to facilitate
absorption) and carefully position so that exudate does not run below the
wound. Use paraffin-based products or zinc paste as a skin barrier. Silver
or Iodine based products can be used if excess exudate is caused by
infection.
In difficult to heal leg ulcers: topical antimicrobials should be considered in
wounds that exhibit local signs of infection or show failure to progress
despite appropriate care. Silver and iodine dressings may be considered.
In a recent study, a number of new sustained slow-release formulations of
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iodine and silver were found to reduce bacterial burden safely and
efficiently. (See section above titled "Identifying the hard to heal ulcer")
Infected wounds: If signs and symptoms of systemic infection are present
choose systemic antibiotics. If signs of local infection only, consider topical
antimicrobials such as silver or Iodine.
Core purposes of a dressing
A dressing can have a number of purposes, depending on the type, severity and position of the
wound, although all purposes are focused towards promoting recovery and preventing further
harm from the wound. Key purposes of are dressing are:
• Stem bleeding - Helps to seal the wound to expedite the clotting process
• Absorb exudate - Soak up blood, plasma and other fluids exuded from the
wound, containing it in one place
• Ease pain - Some dressings may have a pain relieving effect, and others
may have a placebo effect
• Debride the wound - The removal of slough and foreign objects from the
wound
• Protection from infection and mechanical damage, and
• Promote healing - through granulation and epithelialization
An "ideal" wound dressing is one that is sterile, breathable, and conducive for a moist
healing environment. This will then reduce the risk of infection, help the wound heal
more quickly, and reduce scarring.
The ideal wound dressing should have the following characteristics:
• Provide mechanical and bacterial protection

• Maintain a moist environment at the wound/dressing interface
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• Allow gaseous and fluid exchange

• Remain nonadherent to the wound
• Safe in use - Nontoxic, nonsensitizing, and nonallergic (both to the patient
and the medical personnel)
• Well acceptable to the patient (eg, providing pain relief and not influencing
movement)
• Highly absorbable (for exuding wounds)
• Absorb wound odor
• Sterile
• Easy to use (can be applied by medical personnel or the patient)
• Require infrequent changing (if necessary)
• Available in a suitable range of forms and sizes
• Cost effective and covered by health insurance systems
Topical Antimicrobials: When and Where to Use Them in Clinical Practice
Your choice of topical antimicrobial dressings in wound management is a clinical

decision and will depend on the bacterial burden of the wound and the level of
exudate. Topical antimicrobials are most appropriate when used to decrease the
bacterial burden in chronic wounds with active but localised infection.
Antibiotics, Topical
Some topical antibiotics are available without a prescription and are sold in many
forms, including creams, ointments, powders, and sprays. Some widely used
topical antibiotics are
• bacitracin,
• neomycin,
• mupirocin,
• polymyxin B and
• silver sulfasalazine.
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Among the products that contain one or more of these ingredients are Bactroban
(a prescription item), Neosporin, Polysporin, and Triple Antibiotic Ointment or
Cream.
Wounds Measurement by using TIME:
Wound area measurements can help practitioners to monitor the progression of

healing and help to identify the slow to heal leg ulcer early in the consultation
process. The most effective way to do this is to calculate the percentage
reduction of wound area over time, particularly within the first four weeks. A
recent review suggests that a percentage reduction of 30% to 40% over the first
two to three weeks is predictive of healing. Percentage area reduction is also a
useful parameter for assessing a wounds response to treatment. Precise wound
measurements will help to improve the predictive value of healing rates, facilitate
more effective clinical decision-making and ultimately improve patient outcomes.
Ways to Measure Wound Surface Area
• TIME
• SIZE
• SITE
• SHAPE
• HEALNG PROGRESSON
Compression Therapy
The mainstay of conservative treatment for uncomplicated venous ulcers (ABPI

of >0.8) is compression bandaging.
Compression therapy
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Compression applied correctly works to:
• Reduce hypertension in the superficial veins

• Improve venous return by increasing flow velocity in the deep veins
• Reduce leg oedema
• Accelerate blood flow in the microcirculation, reducing tissue fibrosis and
the resultant lipodermatosclerosis.
Types of Compression:
• Below-knee graduated multi layer compression

• Reduced compression
• Compression stockings
• Intermittent pneumatic compression
Below-knee graduated multi layer compression is the mainstay of treatment to

improve venous return. Graduated compression delivers the highest pressure at
the ankle and gaiter area, gradually reducing towards the knee.
Reduced compression may be used in patients with mixed arterial/venous ulcers

under specialist supervision.
Compression stockings are recommended for use in treating some ulcers and
after the ulcer has healed to avoid recurrence.
Intermittent pneumatic compression (IPC) is delivered by a pump device which

inflates and deflates bladders incorporated into sleeves that envelop the
ulcerated leg. There is no evidence to demonstrate better healing rates using IPC
when compared to compression alone. However, IPC may be considered for use
in conjunction with compression bandaging or in patients who cannot tolerate
compression bandaging.
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COMPRESSION PRODUCTS FOR VENOUS LEG ULCERS

Type of compression Examples Characteristics
graduated Multi- Prof ore Applies 40mmHg pressure at the ankle,
layer compression Charing graduating to 17mmHg at the knee;
bandages Cross absorbent & sustainable for a week
reduced Applies 17-20mmHg pressure at the ankle

compression Prof ore Lite and can be left on for up to one week
bandage
1. Used to treat varicose veins; 14 -
Compression stockings 17mmHg ankle pressure
Class 1 light 2. Used to treat severe varicosities &
prevent venous leg ulcers; 18 -
25mmHg ankle pressure
Class 3. Used to treat severe chronic venous
hypertension & severe varicose
veins, & to prevent venous leg
2:medium ulcers in patients with large diameter
legs; 25 - 35 mmHg ankle pressure.
Class 3: strong
Surgery
Effective ulcer management centres both on local wound care and on treating the
underlying cause of ulceration, venous hypertension. Surgical interventions for
venous ulceration focus either on varicose vein surgery and subfascial
endoscopic perforator surgery (SEPS), or on specifically treating the wound bed,
as in skin grafting. Skin grafting is usually only considered in long term ulcers
which fail to heal with conservative treatment. Patients with venous leg ulcer(s)
and obvious varicose veins should be referred for evaluation of suitability for
surgical intervention. The ESCHAR study has shown the significant benefit of
superficial venous surgery in reducing ulcer recurrence.
Follow-Up Care during Treatment
• The patient should be holistically re-assessed each week and progress

recorded.
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• Regular wound measurement will give an accurate indication of ulcer

progress.
• Reassess the appearance of the ulcer: its edge (shallow, punched out,
rolling), base (granulating, sloughy, necrotic), position, surrounding skin,
odour, and signs of infection.
• Reassess the ankle brachial pressure index at 12 weeks if the ulcer is not
fully healed or if it is deteriorating.
Patient education is the key to compliance and both patients and family need be
educated on leg ulcer care. In addition to verbal information written patient
information should be provided. Patients are more likely to comply with treatment
if they are fully informed of the rationale and options for their management.
Topics for education should include:
• Compliance with treatment.

• Good skin care.
• Care of limbs and avoidance of trauma.
• Importance of mobility and exercise.
• Leg elevation when immobile.
Management of Associated Venous Ulcer Complications
• Oedema
• Infection
• Dermatitis
• Allergic contact dermatitis
Leg Oedema
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Leg elevation encourages venous return and may reduce pain and oedema.
Either elevate the foot of the bed at night or place several pillows under the bed
mattress to assist leg elevation.
Infection
Refer to anti-microbial chart above for signs and symptoms of infection.
If there are clinical signs of active infection or cellulitis (e.g. pyrexia, increasing
pain, enlarging ulcer, or cellulitis) wounds should be swabbed. Antibiotics have
little effect on wound healing generally, and should not be used to treat
organisms that have colonized a wound but are not causing clinical signs or
symptoms of infection. Antibiotics are recommended only if there is evidence of
cellulitis or active infection.
Topical antibiotics are frequent sensitizers and should be avoided if possible.
Avoid using compression bandaging if there is evidence of cellulitis.
Reapply dressings daily or on alternate days to allow assessment of the infected

area. (See dressing choice and antimicrobial chart above)
Dermatitis
Venous eczema is commonly associated with chronic venous ulcers and may
present as diffuse erythema, scaling, haemosiderin pigmentation, and exudate
with crusting if there is superadded infection. Frequent emollient application (e.g.
50%/50% white paraffin/soft paraffin gel) plus a short course of mild topical
corticosteroid ointment are the mainstay of treatment.
Allergic Contact Dermatitis
Intitute).
“Leg Ulcer”
Allergic contact dermatitis may complicate venous eczema in a number of

patients.
Common sensitisers include wool, alcohols, topical antibiotics, topical

corticosteroids, cetylstearyl alcohols, parabens, and rubber mixes. Referral for
dermatological patch testing may be appropriate if the dermatitis does not settle,
or if there are concerns about sensitivity to a topical agent, dressing, or bandage
used. Ideally a specific leg ulcer patch-test series should be used.
Treatment Outcomes
Ulcer Heals – Follow-up
Compression stockings
• Measure and fit patients with class 2 graduated compression stockings.
Measuring the Patient for Compression Hosiery
Measurements should be taken, with the patient's feet flat on the ground. As a
general rule the circumference of both legs should be measured so that any
discrepancies between the two legs can be taken into consideration.
• For thigh length stockings: with patient standing, Measure the thigh mid-
region
• Measure the widest part of the calf
• Measure the narrowest part of the ankle, above the ankle bone
• Measure foot length (closed toe hosiery only)
• To approximate length: measure the length from the thigh to the floor/heel
• For knee high stockings measure widest part of calf and narrowest part of
the ankle
Intitute).
“Leg Ulcer”
• Measure from the back of the knee to the floor.

• Replace stockings every six months
Encourage patients to:
• Maintain good skin care

• Remain active
• Elevate limbs when resting
• Present early to their general practitioner (GP) or public health nurse
(PHN) for assessment if ulcer recurs.
Ulcer Fails to Heal (No Reduction in Ulcer Size after I Month)
• Re-assess ulcer (Refer to TIME acronym above to assist in re-

assessment)
Reasons for referral to a vascular specialist:
• No reduction in ulcer size after one month

• Ulcer duration of greater than six months
• Unable to tolerate compression
• Uncontrolled pain
• Frequent recurrence
If there is any doubt about the cause of the ulcer, specialist assessment is
recommended.
When to Refer
Patients with a suspected arterial ulcer with an ABPI of <0.8 need to be referred
for further assessment by a vascular specialist.
Intitute).
“Leg Ulcer”
Patients with an ABPI of <0.5 require urgent referral. These patients may require
surgery or angiography. Compression is contra-indicated in patients with an ABPI
of <0.5 and ulcer care should concentrate on implementing good wound care
practices and appropriate dressings (see Significance of ABPI Results above.
Mixed Arterial/Venous Ulcers
Mixed arterial and venous insufficiency may be seen in approximately 7% of leg

ulcers. Mixed arterial/venous ulcers with an ABPI of between 0.5 - 0.8 may be
treated with reduced compression of 15-25 mmHg.
Referral is also appropriate if the ulcer fails to progress to healing. Mixed ulcers
with ABPI of <0.5 must not be treated with compression and require urgent
vascular referral.
Patients with peripheral arterial disease need to be educated on lifestyle

modification to reduce risks associated with atherosclerotic disease. This
includes education on: smoking cessation, the benefits of exercise and the
importance of a well balanced low fat diet. Aspirin daily and statins to reduce
cholesterol may be considered in medical therapy.
E-N-D
Intitute).

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Vascular Disorders of the lower‐Extremity 2011

Chronic leg ulceration affects about 1% of the middle-aged and elderly

• Chronic venous insufficiency (45-80%)

Venous insufficiency refers to improper functioning of the one-way valves in the

Causes of leg ulcers:

Leg ulcers may be caused by:

• Poor circulation, often caused by arteriosclerosis

trigger or worsen arterial leg ulcers:

Diagnosis/Assessment of leg ulcer:

Accurate assessment is the key to effective ulcer treatment. Comprehensive

Assessment consists of:

Table 1. Past Medical History Suggestive of Venous or Non-venous Disease

Arterial ulcers ;BDR-CROSH

Physical Examination: Diagnostic feature of various types of ulcers:

Table 2. Signs and Symptoms of Leg Ulcers:

contents Venous Arterial

depth Shallow in appearance Deep ulcers with sloughy

These will have signs and symptoms associated with both

contents Venous Arterial

Table 3. Ulcer Examination

Presentation Shallow in appearance Deep ulcers with sloughy

Assessment of Ulcer: Using Wound Bed Preparation Acronym TIME

The concept of TIME incorporates the pathophysiology of chronic wounds such

• T is for Tissue: non-viable tissue in the wound delays healing through

Wound Bed Preparation is the management of the wound to accelerate

Tissue - Remove non-viable or deficient tissue - may be episodic or continuous

• Necrotic Tissue: Sharp surgical debridement if adequate arterial supply -

Moisture imbalance - Correct desiccation and avoid maceration

• Intervention: Rehydrate/debride (Revisit T)

Infection or inflammation - Diagnose and treat infection or inflammatory diseases

• Infection - Diagnosis of infection can be difficult. The interpretation of swab

Edge - Consider surgical intervention or advanced therapies if edge is not

• Intervention: Surgical debridement

Selection and interventions will be based on clinician's knowledge, skills,

Identifying the Hard to Heal Ulcer

Ulcer >6cm2 in size

Ulcer present for >6 months

Unlikely to heal with compression in six months

• A complete blood count (CBC), to check for blood disorders, such as

• Tissue culture, to check for a bacterial or fungal infection.

Doppler ABPI is an objective assessment in identifying arterial disease and

Procedure for ABPI Measurement

A=Highest ankle systolic pressure

• ABPI measurements in patients with diabetes and/or atherosclerosis may

Significance of ABPI Results

>1.3 Suggest non compressible calcified artery

1. ABPI of between 0.92 and 1.30: are considered normal

2. ABPI of greater tha

1. Cleansing and debridement

Venous Leg Ulcers: Treatment

Appropriate Dressing Choice

The emphasis of dressing choice is placed on allergen avoidance and based on

 In uncomplicated ulcers, simple non-adherent dressings are

Core purposes of a dressing

The ideal wound dressing should have the following characteristics:

• Provide mechanical and bacterial protection

• Allow gaseous and fluid exchange

Topical Antimicrobials: When and Where to Use Them in Clinical Practice

Your choice of topical antimicrobial dressings in wound management is a clinical

In uncomplicated ulcers, simple non-adherent dressings are