1. What is a leg ulcer?

A leg ulcer is simply a break in the skin of the leg. The immediate cause is usually an injury, often a minor one, that breaks the skin continuity. In most people such an injury will heal up without difficulty within a week or two. However, if there is an underlying problem the skin does not heal and the area of breakdown may even increase in size. This is a chronic leg ulcer. It may also get infected

2. What causes leg ulcers?

The most common underlying problem causing leg ulcers is disease of the veins of the leg. Venous disease is the main reason for over two thirds of all leg ulcers. There are less common causes of leg ulcers such as disease of the arteries, diabetes, rheumatoid arthritis as well as a large number of even rarer conditions. In some cases two or more conditions may cause damage at the same time. Your doctor will examine you, ask about your history and will do some tests to see what sort of ulcer you have.

The following advice applies to patients with venous ulcers only and may not be appropriate for other sorts of ulcers.

3. How does venous disease cause ulcers?

The veins in your legs are tubes that carry the blood back towards the heart. In humans fluids flow according to a gradient of height, like a mountain stream, downwards, or according to a pressure gradient, as in water supply system, from points of higher pressure to points of lower pressure. This principle applies to the whole circulatory system. In order to overcome this gravitational pressure difference the veins in your legs contain one way valves that should allow blood flow up the leg and not back down the leg. However, these valves are not effective in some people [and blood leaks backwards] or they may be damaged by thrombosis [clotting] in the veins. If the valves are damaged, blood can then flow the wrong way down the leg, cannot overcome the gravity pressure difference and stagnates, resulting in very high pressure inside the veins, especially when you stand up.

While the pressure drops during walking in normal legs, it is still high in varicose veins and it almost does not drop in venous insufficiency [ineffective valves.

As a result the leg swells, blood leaks through the small capillaries which clot, the skin colour changes, becoming dark [melachrosis, discoloration], and the skin breaks down easily, leading to ulcers.

4. Which are the possible consequences of chronic venous disease of the legs?

.   Oedema [leg swelling]. Is due to the high venous pressure when you stand or hang your legs down.

.   Brown pigmentation [melachrosis, discoloration]. Can occur early over the medial aspect of your calf above the ankle and is due to blood leakage and deposition of a pigment [haemosiderin] into the skin [as in tattooing]

.   Localised white atrophy, of porcelain colour, due to skin fibrosis [scarring]

.  Eczema, usually occurring after contact allergy.

.  Lipodermatosclerosis. An indurated but stretchable plaque in the skin of the lower leg

.  Ulcer

.  Skin cancer [2% of all ulcers seen in a specialist’s clinic, but less than 0.2% of all venous ulcers]

5. Which are the treatment options?

Treatment aims firstly at controlling the high pressure in the leg veins and secondly at the ulcer itself. The mainstays of treatment are compression bandaging or graduated elasticated compression stockings and elevation of the limb.

a. Limb elevation. The higher the leg, with less gravity force, the lower the pressure inside the leg veins!!! If the foot is elevated above the level of the heart, the pressure in the foot veins drops to a normal level.

.   Put your legs up whenever you can and as high as you are able - the arm of the sofa is good.

.   Elevate the lower part of your bed [15-20cm, 6-8inches or so] so that when in bed your feet are a little higher than your head. You can use a pillow underneath the mattress or put some old books for the lower part of the bed to sit on them.

b. Compression bandaging or stockings. In order to keep the pressure in the leg veins at the ankle low when you are standing up, you will be treated with compression bandaging or stockings. Several layers of bandages may be required to get the necessary pressure to control the pressure in the veins and promote ulcer healing. Once the ulcer has healed, compression stockings are usually necessary to prevent recurrence. These stockings need to be specially fitted and are much stronger than ordinary support tights. They have to exert a pressure of 30-50mmHg on your calf. If you have difficulty putting your stockings on, you can buy a special stocking applicator.

c. Dressings [as outpatient].

The nurse will use a number of different dressings under the bandages, depending on the state of the ulcer itself. Contact allergens must be avoided as well as sticking of dry dressings to the base of the ulcer -hence the use of greasy ointments, non-stick dressings hydrocolloid [gels] and medicated dressings. These dressings may have to change as the ulcer progresses.

d. Intense treatment for large and difficult ulcers

.   Bed rest and leg elevation

.   Treatment of infection. An ulcer may quickly be colonised by a variety of bacteria so frequent cleansing with antiseptics [iodine and eosine] is essential. Antibiotics are almost never necessary. Local irrigation [pottasium permanganate and wet compresses] can be used.

.   Removal of slough and dead tissue over the ulcer is necessary. It can be achieved surgically [with a scalpel] which is the most effective method, or by the use of enzymes, gels and alginates, put over the area with the various dressings.

.   Healing stage. Soft tissue wounds heal by a complex process, starting with granulation [red, friable new fleshy tissue] and progressing by migration of the skin surface from the edges of the wound [epithelialization]. Cleansing with antiseptics is still necessary. Various layers of bandaging may be used to promote healing, which would include paraffin gauges [vaselin, non-sticky] and then sterile gauge, medicated gauges [cotton impregnated with zinc paste, hydroxybenzoates, ichtamol and zinc oxide], gels and finally a compression bandage or elastic hosiery.

.  Surgery. Only rarely and only for the largest or very resistant ulcers either a skin graft or an operation on the veins may be necessary. If your ulcers are due to varicose veins, then these may be treated, usually when the ulcer has healed.

6. How long will it take the ulcer to heal?

It has usually taken many years for the venous disease to cause the ulcers, so it is not surprisingly that the ulcers may take a fairly long time to heal. Although most venous ulcers will heal up in 3-4 months, a small proportion will take considerably longer. Don’t despair! Even in those resistant cases treatment is eventually successful in 90% of cases.

7. How can I stop the ulcer coming back?

Once your ulcer has healed, it does not mean that your problem is over. Although the skin is intact, the underlying problem with the veins remains and you must take precautions to prevent the ulcer recurring.

.  Wear compression stockings, grade II [not support tights!] below the knee, at all times during the day. Elderly or infirm patients should wear them continuously and a relative or a district nurse may change them twice a week. The compression hosiery is required for a lifetime in most cases.

.   Elevation of the legs whenever possible

.  Keep the skin in good condition by using plenty of moisturising cream to prevent dryness.

.  Frequent walking with the stockings on is mandatory. The massaging effect of the muscles during walking eases the heaviness and pain.

.  Weight loss, fresh fruit, exercise and abstinence from smocking are also vital to help heal your ulcer as well as for your general health.