What causes Leg Ulcers?

As the name suggests, venous leg ulcers arise due to a problem with the veins in the lower limb. The main deep veins within the legs contain valves that help to prevent the backflow of blood when it is travelling upwards against gravity from the legs back to the heart. When the muscles in the calf and foot contract on movement, they also help to squeeze the blood upwards on its journey.

When the veins don’t work properly, blood flows backwards and pools in the veins. This is known as venous insufficiency and it is the main cause of ulceration (BPS, 2017). Reduced mobility which leads to the calf-muscle pump not working well also contributes to an increased amount of blood in the veins.

This pooling of blood results in increased blood pressure in the vein. Over time, a chronic inflammatory response occurs, which can result in skin changes, swelling and ultimately, ulceration (BPS, 2017).

However, skin changes take time to worsen, so if they are identified early, steps can be taken to stop them becoming worse. Some of the most common skin changes are:

Who is at risk of developing a venous leg ulcer?

Multiple pregnancies

Reduced mobility

Deep vein thrombosis

Varicose veins

Previous injury to the leg via trauma or surgery

Increasing age

Chronic oedema

A family history of venous leg ulcers (NHS, 2016)

Symptoms

Dry, itchy, papery skin

Pain

Swelling / Recurrent oedema

Wound fluid (exudate)

Odour

Complications

Open wounds are at risk of infection. If there is a worsening of any of your symptoms, for example, more pain, odour, or fluid or if your wound enlarges in size, or the skin surrounding the wound becomes red and/or hot, you should seek medical advice immediately.

How do I know if I have a venous leg ulcer?

Before beginning any treatment, your healthcare professional will confirm that your leg ulcer is venous. It is important to have this confirmation to make sure that the treatment you receive is right for your wound type and will not be affected by any other conditions you may have. Your healthcare professional will do this by carrying out a full assessment which will include reviewing your medical history and current health, plus examining your skin and wound.

How will my leg ulcer be managed?

The management of your leg ulcer will aim to relieve your symptoms and/or heal your wound using a combination of wound care and compression therapy.

Wound dressing

A dressing will be applied to your wound to help to manage the symptoms such as fluid production, odour and pain. The dressing will be selected according to your needs. The dressing will protect your wound from infection and prevent the wound from drying out, which can delay healing.

Skin care

Whether your ulcer is open or closed, the skin around your wound should be kept intact and supple by cleansing and moisturising. This will help prevent it from becoming fragile and prone to injury and breakdown.

Compression

Compression therapy also helps these symptoms by addressing the underlying cause: venous insufficiency. Compression applied to the limb helps to provide resistance to the muscles on movement, helping them to squeeze blood within the vessels more efficiently. The compression delivered is graduated, meaning it is greater at the ankle and reduces towards the knee. This improves the return of blood to the heart, reducing pressure in the vein and alleviating congestion and fluid in the tissues (Callaghan, 2018).

Compression choice

A variety of different compression options exist, including bandaging, hosiery, kits and wraps. Your healthcare professional will help you to select the most appropriate option for you and your wound. Factors such as the size of your ulcer, the presence of swelling, the overall shape and size of your limb and your preferences (Callaghan, 2018).

Compression Bandaging

Bandages are usually selected If you have a large wound and/or if your limb is not the usual cylindrical shape. This is because the presence of large bulky dressings or distorted shape means that padding will be needed to restore a cylindrical shape so that the compression bandaging delivers the correct compression to the limb.

Bandaging should only be used to reduce wound size and/or swelling; if and when these symptoms are resolved, a different compression option can be considered.

Compression Wraps

Compression wraps also have the benefits of hosiery, while also being adaptable, allowing adjustment of the compression delivered as the limb changes, e.g. as swelling reduces.

Like hosiery, it is important that you are assessed and measured by a healthcare professional to make sure your product is right for you, and that it fits correctly.

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Hosiery kits

  • Hosiery kits are as effective as bandaging for healing ulcers in patients with a cylindrical limb shape and small to medium-sized wounds (Ashby et al, 2014). They can be applied and removed by the wearer, making activities such as showering and self-care much easier. They are also ideal for preventing the recurrence of ulceration on you have healed.

  • It is important that your compression hosiery fits well in order to be effective. If it is too tight, it can result in restricted blood flow and skin damage, and if it is too big, it may slip and fall down. It is important that you are measured by your clinician and that the correct class (strength) of compression is used, for example, Class I garments offer light support, while class III offer strong support). The type of fabric that your garment is made from will also influence how it works. For example, a thinner fabric may be used for prevention, while a stiffer fabric may be needed if swelling is present. Garments are available in a range of ready to wear sizes, but if you do not fit into these, your clinician may recommend made to measure hosiery.

  • Different manufacturers provide garments in different styles, colours, fabrics and classes so your clinician can help you to select the best one for you. The specifications of garments can vary among manufacturers so your clinician will use the measuring guidelines for the garment you need and should check that it fits properly.

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Prevention of recurrence

Once your leg ulcer is healed, wearing a compression garment in the long-term has been shown to prevent recurrence, while patients who do not have a high rate of their ulcer returning (Ashby et al, 2014). You should undergo regular review to monitor your general health and to reduce your risk of skin breakdown. As with an active ulcer, your healthcare professional should help you to select a compression garment suitable to your needs.

Questions and answers

Why do I need to keep a dressing on my leg?

The dressing will protect your wound from the environment, reducing the risk of infection. It will also help to manage any symptoms that might be causing you problems such as wound fluid or odour. Finally, it will create a moist environment which promotes quicker healing.

Won’t it be better to let the air get to the wound?

Moist wound healing has been shown to be the best environment for wound healing in the majority of people. Maintaining an environment that is not too wet or dry increases the speed of healing. Your healthcare professional will help you to select a dressing to achieve the perfect balance for your wound.

Why is it important that I keep wearing compression hosiery once my leg ulcer heals?

Compression hosiery addresses the underlying cause of venous ulceration, by helping to improve the return of blood from the limb to the heart. Once your ulcer is healed, the underlying cause is still there. For this reason, you should continue to wear your garment. Evidence shows that people who wear compression following healing have a lower rate of recurrence than those who don’t.

I find the compression bandages restrictive and miss daily showers, why do I have to wear them continuously?

Bandaging can be bulky, hot and uncomfortable as well as inconvenient. Remember if you need to wear bandaging, it is not forever, just until your limb size has reduced and/or your wound has reduced in size enough to not need bulky dressings.

I find my legs itchy and dry around the wound site, what can I do to relieve the symptoms?

Good skin care in the form of cleansing and moisturising can help to alleviate some of these symptoms. Be sure to use bland emollients and make sure they do not affect your compression garment by applying in advance of wearing your garment.

References

Ashby RL, Gabe R, Ali S, Adderley U (2014) Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg Ulcer Study IV, VenUS IV): A randomised controlled trial. Lancet 383(9920): 871–9

Best Practice Statement (BPS) (2016) Holistic management of venous leg ulceration. London: Wounds UK. Available to download from: www.wounds-uk.com

Callaghan R (2018) What to expect on your venous leg ulcer treatment journey: from diagnosis to healing. In This Together 2: 16–18. Available to download from: www.daylong.co.uk

Guest JF, Ayoub N, McIlwraith T et al (2015) Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open 5: e009283. doi:10.1136/bmjopen-2015-009283

NHS (2016) Causes of venous leg ulcers. Available online at: http://www.nhs.uk/Conditions/Leg-ulcer-venous/ Pages/Causes.aspx (accessed 16.09.2016)

National Institute for Health and Clinical Excellence (2013) Clinical knowledge summaries: Leg ulcer – venous. Available online at: http://cks.nice.org.uk/leg-ulcer- venous#!topicsummary (accessed 25.08.2016)

SIGN (2010) Management of chronic venous leg ulcers: A national clinical guideline 120. Available at http://www. sign.ac.uk/pdf/sign120.pdf (accessed 12.07.2016)