Venous leg ulcers are common in older people. The most important part
of treatment is for compression bandages to be applied correctly by a
nurse. Keep as active as possible, but elevate your leg when you are
resting. Other treatments may be advised in some cases such as a skin
graft or vein surgery. After an ulcer has healed you should wear a
support stocking each day which helps to prevent it recurring.
What is a venous leg ulcer?
A skin ulcer is
where an area of skin has broken down and you can see the underlying
flesh. Venous leg ulcers are the most common type of skin ulcer. They
mainly occur just above the ankle. They usually affect older people and
are more common in women. About 1 in 50 people develop a venous leg
ulcer at some stage. Venous leg ulcers can be painless, but some are
painful. Without treatment, an ulcer may become larger and cause
problems in the leg.
(Non-venous skin ulcers are less common.
For example, a skin ulcer may be caused by poor circulation due to
narrowed arteries in the leg, problems with nerves that supply the
skin, or other problems. The treatment for non-venous ulcers is
different to that of venous ulcers.)
The rest of this leaflet deals only with venous leg ulcers.
What causes venous leg ulcers?
The root of
the problem is increased pressure of blood in the veins of the lower
leg. This causes fluid to 'ooze out' of the veins beneath the skin.
This causes swelling, thickening, and damage to the skin. The damaged
skin may eventually break down to form an ulcer.
The increased
pressure of blood in the leg veins is due to blood collecting in the
smaller veins next to the skin. The blood tends to collect and 'pool'
because the valves in the larger veins are damaged. The valves may be
damaged by a previous thrombosis (blood clot) in the vein, or by
varicose veins. Gravity causes blood to backflow through the damaged
valves and pool in the lower veins.
How is a venous leg ulcer diagnosed?
The
appearance of a venous leg ulcer is usually fairly typical. It often
looks different to ulcers caused by other problems such as poor
circulation or nerve problems. To rule out poor circulation as a cause
it is usual for a doctor or nurse to check the blood pressure in the
ankle and in the arm. The ankle blood pressure reading is
divided by the arm blood pressure reading to give a blood pressure
ratio called the 'Ankle Brachial Pressure Index (ABPI)'. If the ratio
is low (less than 0.8) it indicates that the cause of the ulcer is
likely to be poor circulation (peripheral vascular disease) rather than
venous problems. This is very important to know as the treatments are
very different. An ABPI may be checked every six months or so to make
sure the circulation to the legs remains good.
Certain blood and
urine tests may also be done to rule out conditions such as anaemia,
diabetes, kidney problems, and rheumatoid arthritis which may cause or
aggravate certain types of skin ulcer.
What is the treatment for venous leg ulcers?
The
ulcer is dressed in a similar way to any other wound. Typically, a
nurse will do this every week or so. The wound is cleaned when the
dressing is changed - normally with ordinary tap water. However, an
ulcer is unlikely to heal with just dressings. In addition to a
dressing, the following treatments help the ulcer to heal.
Compression bandaging
This is the most
important part of treatment. The aim is to counteract the raised
pressure in the leg veins. This gives the best chance for the ulcer to
heal. The common method is for a nurse to put on 2-4 layers of bandages
over the dressing. When the bandages are put on, the pressure is put
highest at the ankle, and gradually less towards the knee and thigh. (A
compression stocking over the dressing is sometimes used as an
alternative, but not thought to be as good as bandaging.)
The
bandages are re-applied every week or so when the ulcer dressing is
changed. It is best to put the bandages on after you have elevated the
leg for several hours or overnight (see below). So, make extra effort
to keep your leg elevated just before the nurse is due to see you.
A note of caution:
when you have a compression bandage on you should still be able to move
your ankle around. Occassionally, the compression is too tight, or it
may affect the circulation in the legs. Therefore, take off the
bandages straight away if your foot changes colour or temperature, or
if you have increasing pain. Then see your doctor or nurse for advice.
Elevation and activity
When you are resting,
if possible, try and keep your leg elevated (raised) higher than your
hip. This is particularly important if your leg is swollen. The aim is
to let gravity help to pull fluid and blood in the right direction -
towards the heart. This reduces swelling in the leg, and reduces the
pressure of blood in the leg veins.
Try to set 3 or 4 periods
per day of about 30 minutes to lie down with your leg raised. For
example, lie on a bed or sofa with your foot on a couple of pillows.
However, do not spend all your time in bed or resting. For the rest of
the time, keep as active as you can, and do normal activities. If
possible, regular walks are good, but do not stand still for long
periods.
When you sleep overnight, if possible, try to keep
your leg raised. You can do this by putting some pillows under the
bottom of the mattress. (It may not be possible to sleep like this if
you have certain other medical problems or disabilities.)
Other treatments
In some people, other
conditions such as anaemia, poor nutrition, swelling of the legs, and
other medical problems may mean that the skin has less chance of
healing well. Other treatments may be needed to help heal a venous leg
ulcer. For example:
-
Try to stop smoking if you are a smoker. The chemicals in cigarettes may interfere with the skin healing.
-
Antibiotics are sometimes advised for short periods if the skin and tissues around the ulcer become infected.
-
Painkillers if the ulcer is painful.
-
Skin care. The skin around an ulcer is often inflamed or
scaly. Your doctor or nurse will advise on creams that will reduce
inflammation and keep the surrounding skin as healthy as possible.
-
Dietary advice if your diet is not very good. Also, if you
are overweight then losing some weight may help. Obesity is a 'risk
factor' for developing venous leg ulcers.
-
Iron tablets or other treatments if your are anaemic.
-
A skin graft may be advised for a large ulcer, or for one that does not heal well.
-
Surgery for varicose veins or other vein problems may be
advised in some cases. This may correct the 'back pressure' of blood
pooling in the veins, and allow an ulcer to heal.
What is the outlook (prognosis)?
Up to 7 in
10 venous ulcers heal within 12 weeks if treated with compression
bandaging which is re-applied every week or so. If compression is not
used and an ordinary dressing or compression stockings alone are used,
the chance of healing is less.
Preventing a recurrence of venous skin ulcers
Venous
leg ulcers commonly recur (come back) after they have healed. To
prevent this, your should wear a compression (support ) stocking during
the daytime for at least five years after the ulcer has healed. This
counteracts the raised pressure in the veins that causes venous leg
ulcers. You should get a new stocking about every six months as the
elastic tends to 'go' after a while. Compression stockings can be
prescribed or bought at pharmacies. They come in different sizes - your
pharmacist will advise. Compression stockings for the prevention of
venous leg ulcers are usually 'below knee' in length rather than thigh
length.
There are different classes (strengths) of compression
stockings - class 1, 2 and 3. The higher the class (class 3) the
greater the compression. Ideally, wear class 3 stockings. However, some
people find class 3 stockings too tight and uncomfortable, but class 2
may be fine. It is still better to wear some sort of compression
stocking than none at all. Note: proper compression stockings used for
medical purposes are different to the support stockings or tights sold
in ordinary clothing shops.
A leg ulcer is much less likely to recur if you wear compression stockings regularly.
Sometimes surgery for varicose veins or other vein problems is advised after an ulcer has healed to help prevent a recurrence.
Further help and information
Lindsay Leg Club Foundation
PO Box 689, Ipswich, IP1 9BN
Tel: 01473 749565 Web: www.legclub.org
Aims to motivate and empower patients to take ownership of their care.
Also seeks to advance education in all aspects of leg health among
sufferers, carers, and health professionals.
References
© EMIS and PiP 2008 Updated: 15 May 2008
