Venous Skin Ulcer

Topic Overview

What is a venous skin ulcer?

A venous skin ulcer, also called a stasis leg ulcer, is a shallow wound that develops when the leg veins do not move blood back toward the heart normally (venous insufficiency).

Venous skin ulcers typically develop on either side of the lower leg, above the ankle and below the calf. See a picture of areas affected by venous skin ulcers .

What causes venous skin ulcers?

The veins in the body have valves that keep blood flowing toward the heart. In a condition called venous insufficiency, the valves are damaged and allow some blood to back up in the vein. The slowed circulation causes fluid to seep out of the overfilled veins into surrounding tissues, causing tissue breakdown and ulcers. See a picture of abnormal blood flow caused by venous insufficiency .

Less frequently, blocked veins are a contributing factor in the development of venous skin ulcers.

What are the symptoms?

The first sign of a venous skin ulcer is the appearance of dark red or purple skin over the affected area. The skin may also become thickened and dry and itchy. Contact your doctor when you first notice the signs of a venous ulcer because you may be able to prevent an open wound (ulcer) from forming.

Without treatment, an ulcer may form. The wound may be painful, and you may also have swollen and achy legs. You may get rashes, such as contact dermatitis, on the skin around the ulcer.

Because venous skin ulcers are a result of poor blood circulation, these wounds are often slow to heal. If an ulcer becomes infected, there may be an odor, pus draining from the wound, and increased tenderness and redness.

How are venous skin ulcers diagnosed?

Venous skin ulcers can usually be diagnosed with a health history and physical exam. Your doctor may also use duplex Doppler ultrasound. This shows how well your blood is moving up through the lower leg.

How are they treated?

Improving circulation is critical in the treatment of venous skin ulcers. You can accomplish this by elevating your legs above the level of your heart when you can and, during your waking hours, using specially fitted stockings called compression stockings, designed to help prevent blood from pooling in your legs. See a picture of how to put on compression stockings .

More aggressive medical treatments, such as skin grafting and vein surgery, are available for venous skin ulcers that take longer than 6 months of treatment to heal or that become infected.

What increases your risk for venous skin ulcers?

Factors that contribute to venous insufficiency and increase your risk of developing venous skin ulcers include:

• Deep vein thrombosis, which can result from a severe leg injury (such as a broken or crushed bone) or leg surgery (including knee replacement and varicose vein procedures). Deep vein thrombosis can also develop when you don't move around for long periods (for example, if you are paralyzed or bedridden).
• Obesity.
• Pregnancies, which may aggravate an existing venous problem.
• A family history of varicose veins, especially if you also have reverse blood flow in a saphenous vein, which runs up the inner thigh.
• A blood-clotting disorder.

Your risk of developing a venous skin ulcer is further increased by smoking, lack of physical activity, excessive alcohol use, aging, poor nutrition (especially insufficient protein), and work that requires many hours of standing.

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	Venous skin ulcers: Using compression stockings

Symptoms

Venous skin ulcers typically develop on the inside of the lower leg, above the ankle bone and below the calf. Less frequently, they develop on the outside of the lower leg. See an illustration of areas affected by venous skin ulcers .

The first sign of a skin ulcer is the appearance of dark red or purple skin over the affected area. It may also become thickened and dry and itchy. Contact your doctor if you have any of these warning signs.

Without treatment, an open wound (ulcer) may form. Venous skin ulcers often weep clear fluid and are covered with a yellowish film. The ulcer's edge is typically ragged, and the skin around it often thickens and turns reddish brown in color. You may also have:

• Pain, although it is not always present.
• Swelling and aches in the legs that are worse at the end of the day and when standing and are relieved when the legs are elevated above the level of the heart.
• Sensitized skin. The skin around the affected area becomes susceptible to rashes from topical medicines, perfumes, and other ingredients in creams and lotions (contact dermatitis).

Because venous skin ulcers are a result of poor circulation, these wounds are often slow to heal. Contact your doctor when you first notice the signs of a venous ulcer because you may be able to prevent an ulcer from forming. If an ulcer has already formed, get immediate treatment because smaller ulcers that have not been present long tend to heal faster than larger ones.

If an ulcer becomes infected, there may be an odor, pus draining from the wound, and increased tenderness and redness. Call your doctor if you have signs of infection.

Exams and Tests

It is important to know whether a leg ulcer is a venous skin ulcer or another type of skin ulcer before deciding which treatment is appropriate. Compression stockings, the primary treatment for venous skin ulcers, will make an arterial ulcer worse.

Skin ulcer type can usually be diagnosed with a health history and physical exam. Your doctor may also use duplex Doppler ultrasound to confirm whether and where venous insufficiency is playing a part in ulcer formation.

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.¹

Treatment Overview

The key to treating venous skin ulcers is using compression stockings and elevating your legs. Compression reverses the underlying circulation problem in the legs and helps control painful swelling from fluid buildup (edema). People who stick to a long-term compression treatment regimen have much greater treatment success than those who do not. Also, continuing compression after healing prevents ulcers from coming back.¹

See an illustration of how to put on compression stockings .

Prevention

If you are at risk of developing a venous skin ulcer or have had one before, wear compression stockings during your waking hours and try to elevate your legs as often as possible.

Compression stockings are also important if you have had a deep vein thrombosis, or blood clot. Studies show that below-the-knee compression stockings lower the risk of postthrombotic syndrome, including venous skin ulcers.²

For more information, see:

Venous skin ulcers: Using compression stockings.

If you have poor blood circulation (reflux) just below the skin, simple vein surgery and compression treatment may prevent ulcers from coming back.³

Treatment

If you have developed a venous skin ulcer, your treatment may include:

• Compression bandages and elevation. If an ulcer has formed, a dressing may be placed over the wound before the compression is put on. The dressing may contain medicine to help heal the ulcer.
• Debridement, or removal, of any dead tissue on the wound. Debridement is often used to help a skin ulcer heal properly.
• A balanced diet, dietary supplements, and exercise. For more information, see the Home Treatment section of this topic.

If your skin ulcer does not heal within 3 to 6 months of standard compression treatment, your doctor may recommend additional treatment. A number of options are available, including:

• Pentoxifylline, an oral medicine that speeds healing when used with compression.⁴
• Antibiotics, used only when an infection is present. They do not improve ulcer healing.
• Intermittent pneumatic compression (IPC) pump. These devices alternately inflate and deflate knee-high boots, which results in decreased pooling of blood in the legs. IPC pumps can be used at home for ulcers that have not healed with conventional compression therapy.
• Skin grafting, an effective treatment for deep or long-standing and difficult-to-heal skin ulcers.
• Vein surgery, which does not improve healing but may help prevent recurring ulcers. This treatment is rarely done, because it is only useful for specific vein problems.⁵ For more information on vein surgery, see the topic Varicose Veins.

Other treatment options that show promise include:

• Injections of growth factors at the ulcer site. Early studies show that one factor, granulocyte-macrophage colony-stimulating factor (GM-CSF), increases the likelihood that chronic leg ulcers heal completely.¹
• Mesoglycan. One large study found that injections of mesoglycan, which is found naturally in many tissues in the body, significantly increased healing when compression bandages were used for 6 months.⁶

Home Treatment

Venous skin ulcers can take months to heal and often recur. You can reduce your healing time and your risk of having an ulcer recur by taking the following important measures:

• Carefully follow your doctor's instructions for wound care, and ensure that your compression bandages are changed regularly. Bandages are typically changed weekly.
• Make sure you're getting enough vitamin C and flavonoids, which are available at most drug and health food stores. They have a proven benefit for venous skin ulcer healing.⁷
• Avoid smoking and excessive alcohol use, both of which impair skin ulcer healing and prevention.
• For both treatment and prevention, elevate your legs above the level of your heart whenever possible. Prop the foot end of your bed up 6 in. (15 cm) to 8 in. (20 cm) on blocks. During waking hours, try to elevate your legs higher than your heart for 30 minutes, 3 to 4 times a day.
• Maintain a balanced, nutritious diet.
• Exercise regularly. Walking is an excellent activity for improving lower leg circulation.
• Avoid prolonged standing or sitting, both of which slow healing.
• Ask your doctor whether aspirin may help your ulcer heal more quickly.
• Try using an herbal preparation containing substances extracted from horse chestnuts (aescin). Studies have shown that aescin can help reduce swelling and ease the pain caused by venous insufficiency. Be sure to tell your doctor about any herbal supplements you are taking.⁸

Once your wound has healed, wear your compression stockings regularly, removing them only for bathing and sleeping. Compression is the key to preventing venous skin ulcers. For more information, see:

Venous skin ulcers: Using compression stockings.

Other Places To Get Help

Organization

Related Information

• Deep Vein Thrombosis
• Diabetic Nephropathy
• Varicose Veins

References

Citations

1. De Araujo T, et al. (2003). Managing the patient with venous ulcers. Annals of Internal Medicine, 138(4): 326-334.

2. Prandoni P, et al. (2004). Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: A randomized, controlled trial. Annals of Internal Medicine, 141(4): 249-256.

3. Barwell JR, et al. (2004). Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): Randomized controlled trial. Lancet, 363(9424): 1854-1859.

4. Phillips TJ, et al. (2000). Prognostic indicators in venous ulcers. Journal of the American Academy of Dermatology, 43(4): 627-630.

5. Valencia IC, et al. (2001). Chronic venous insufficiency and venous leg ulceration. Journal of the American Academy of Dermatology, 44(3): 401-421.

6. Nelson EA, et al. (2006). Venous leg ulcers. Online version of Clinical Evidence (15): 1-20.

7. Katz DL (2001). Diet and wound healing. In Nutrition in Clinical Practice, pp. 147-149. Philadelphia: Lippincott Williams and Wilkins.

8. Suter A, et al. (2006). Treatment of patients with venous insufficiency with fresh plant horse chestnut seed extract: A review of 5 clinical studies. Advances in Therapy, 23(1): 179-190.

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