Leg Ulcers - Information

What is a leg ulcer?

A leg ulcer is simply a break in the skin of the leg which allows air and bacteria to get into the underlying tissue. This is usually caused by an injury, often a minor one, that breaks the skin. In most people, such an injury will heal up without difficulty within a week or two. However, when there is an underlying problem, the skin does not heal, and the area of breakdown can increase in size. This is a chronic leg ulcer.

 

What causes leg ulcers?

The most common underlying problem causing chronic leg ulcers is disease of the veins of the leg, known as venous disease. It is the main reason for over two-thirds of all leg ulcers. The causes of leg ulcers can be categorized as follows:

• Venous Disease: Caused by veins not working properly, accounting for about 80% of leg ulcers.
• Arterial Disease: Caused by the arteries not working properly, accounting for about 15% of leg ulcers.
• Other Causes: Includes diabetes, rheumatoid arthritis, and some rare conditions, making up about 5% of leg ulcers.

In some cases, two or more conditions may be causing damage at the same time. Your doctor will examine you and perform tests to determine what type of ulcer you have. The following advice applies to venous ulcers and may not be appropriate for other types of ulcers.

 

How does venous disease cause ulcers?

The veins in your legs are tubes that carry the blood back from the foot towards your heart. The veins in your legs have one-way valves that ensure the blood flows up the leg and not back down. In some people, these valves don’t work very well or can be damaged by thrombosis (clots) in the veins. If the valves are damaged, blood can flow the wrong way down the veins, resulting in very high pressure in the veins when you stand up. This abnormally high pressure damages the skin and leads to ulcers.

 

How will I be treated?

Treatment of a venous leg ulcer happens in two ways:

• Controlling the high pressure in the leg veins
• Treatment of the ulcer itself

The mainstays of treatment are compression bandaging or stockings and elevation of the limb.

Elevation of the limb

The higher the leg, the lower the pressure in the leg veins. If the foot is elevated above the heart, the pressure in the foot drops to a normal level. Put your legs up whenever you can and as high as you are able. Elevate the lower end of your bed (6 inches or so) so that when in bed, your feet are a little higher than your head. You can use some old books for this.

Compression bandaging or stockings

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 veins. Once the ulcer is healed, compression stockings are usually necessary to prevent the ulcer from returning. These stockings need to be specially fitted and are much stronger than ordinary support tights. If you have difficulty putting on your stockings, you can buy a special stocking applicator.

Dressings

The nurse will use a number of different dressings under the bandages depending on the state of the ulcer itself. These dressings may change as the ulcer progresses.

Surgery

Very occasionally, a skin graft or an operation on the veins may be necessary. If your ulcer is due to varicose veins, these may be treated, usually once the ulcer has healed, to prevent it from coming back. Other treatments such as laser therapy, radiofrequency ablation therapy, or foam sclerotherapy (injections) may be used to help prevent further recurrence. Arterial ulcers may benefit from balloon angioplasty (stretching an artery with a balloon) to relieve narrowing and obstruction of the arteries. This may be combined with the use of a stent (a metallic cage to keep the vessel wall open). The insertion of new leg arteries (bypass operation) may be required in some circumstances.

Antibiotics

Antibiotics are occasionally required to treat ulcers, particularly if there is evidence of infection in the surrounding tissues and skin (cellulitis) or lymphatic channels (lymphangitis).

 

How long will it take the ulcer to heal?

It has usually taken many years for venous disease to cause the ulcers, so it is not surprising that the ulcers may take a fairly long time to heal. Although most venous ulcers will heal within 3-4 months, a small proportion will take considerably longer. Even in resistant cases, treatment is eventually successful.

 

Is there any risk of losing my leg?

It is very rare for venous ulceration of the leg to lead to amputation. Even larger ulcers can usually be treated successfully. However, for arterial ulcers, if it is not possible to insert a new artery or perform an angioplasty, amputation may be considered in severe cases.

 

How can I stop the ulcer from coming back?

Once your ulcer is healed, the underlying problem with the veins remains, and you must take precautions to prevent the ulcer from recurring:

• Wear compression stockings (or bandages in a few severe cases) at all times during the day.
• Elevate your legs whenever possible.
• Keep the skin in good condition by using plenty of moisturising cream to prevent dryness.
• Weight loss, fresh fruit, exercise, and stopping smoking are also vital to help heal your ulcer and for your general health.

 

How can I help myself?

Stop smoking: This is one of the major risk factors for vascular (circulatory) disease. It is difficult to give up, but help is available. Speak to your doctor or the NHS Smoking Cessation Service on 0800 169 0169.

Take regular exercise: Using your foot and leg muscles encourages circulation and also helps you control your weight. Avoid standing or sitting in one position for a long time. Walk as much as possible, or just move your feet around and up and down.

Eat a healthy diet: Include protein, oily fish, fresh fruit, and vegetables in your diet, or speak to your doctor or dietician for advice. Vitamins A, C, and E (the antioxidants) are thought to be beneficial to the circulation.

Elevate your legs: If you are advised to put your legs up, ideally rest with your ankles above waist height. Don’t cross your legs when sitting or allow the edge of the chair to press into the back of your legs.

Wear support stockings: If these have been advised. If you have a problem with your dressings or bandages or if your stockings become loose, tell your nurse straight away.

Avoid tight clothing: Avoid tight clothing on your legs and wear comfortable, well-fitting shoes. See a chiropodist regularly (at least every 3 months) and take care when cutting toenails.

Protect your skin and legs: Keep your feet and legs warm but avoid extremes of temperature (e.g., hot baths, sunburn, sitting too close to the fire). Use mild soap or soap substitute to keep your skin clean, and keep it supple with a bland moisturizer. Your doctor or nurse can advise you about products to use. Take care not to bang your feet or legs on sharp corners or objects.

Inspect your feet and legs regularly: Look for sores or changes in color – use a mirror to help. Do not delay in seeking help if you think you are developing an ulcer.