What are venous leg ulcers?
Venous leg ulcers are open wounds that develop on the lower leg, typically around the ankle area, caused by problems with blood flow in your leg veins. These sores can be slow to heal and may persist for weeks, months, or even years if left untreated.
Venous leg ulcers are late indicators of chronic venous insufficiency, where the veins in your legs struggle to pump blood back to your heart effectively. When blood pools in the lower legs due to faulty valves or damaged veins, it creates increased pressure that can eventually break down the skin and underlying tissue.
Venous leg ulcers affect approximately 0.3% of the Western adult population, but their impact on daily life can be significant. Many people with venous ulcers experience pain, difficulty walking, and reduced quality of life, as well as the need for frequent dressing changes and compression bandaging. However, with proper treatment and management, most venous leg ulcers can heal successfully.
“Up to 80% of lower limb ulceration is because of venous disease, therefore timely review with a vascular specialist is essential for the healing of most leg ulcers and prevention of recurrence.”
Lily Benton
Vascular Nurse
How venous leg ulcers develop
Venous leg ulcers don't appear overnight—they're usually the result of long-term problems with your leg veins. Understanding how they develop can help you recognise early warning signs and seek treatment before an ulcer forms.
The process typically begins with chronic venous insufficiency, where the valves in your leg veins become damaged or weakened. These valves normally prevent blood from flowing backwards, but when they fail, blood begins to pool in the lower parts of your legs.
This pooling creates several problems:
- Increased pressure: Blood accumulating in the veins puts extra pressure on the vein walls and surrounding tissue
- Poor oxygen supply: Areas with poor blood flow don't receive enough oxygen and nutrients
- Inflammation: The body's response to poor circulation can cause swelling and skin changes
- Skin breakdown: Over time, the combination of pressure, poor circulation, and inflammation weakens the skin until it breaks down into an open wound
Who is affected?
Venous leg ulcers can affect anyone, but certain groups are more likely to develop them. Chronic venous insufficiency affects approximately 5% and chronic leg ulcer approximately 1% of the adult population of developed countries.
People at higher risk include:
- Older adults: Risk increases with age, particularly after 65, as vein valves naturally weaken over time
- Those with a history of leg injuries: Previous trauma to the leg can damage veins and increase ulcer risk
- People who've had blood clots: Past deep vein thrombosis (DVT) can permanently damage vein valves
- Those who stand for long periods: Jobs requiring prolonged standing put extra strain on leg veins
- People with varicose veins: Visible varicose veins often indicate underlying venous insufficiency
- Individuals with mobility issues: Limited movement reduces the natural pumping action that helps blood flow
Signs and symptoms of venous leg ulcers
The symptoms of a venous leg ulcer include pain, itching and swelling in the affected leg. There may also be discoloured or hardened skin around the ulcer, and the sore may produce a foul-smelling discharge. Understanding the progression of symptoms can help you seek treatment before an ulcer develops.
Pre-ulcer stage: venous stasis dermatitis
The earliest signs often appear as venous stasis dermatitis - a skin condition that develops before ulcers form:x
- Brown or red discolouration: Darkened or discoloured skin around the ankle that may spread up the leg
- Skin texture changes: Skin that feels leathery or waxy to the touch
- Varicose eczema: Dry, flaky, or scaly patches that may crack or bleed
- Visible varicose veins: Swollen and enlarged veins that are often visible on the legs
- Progressive swelling: Legs may become swollen, especially at the end of the day or after long periods of standing
Early warning signs
Before an ulcer develops, you might notice these important symptoms:
- Skin changes: Brown staining (hemosiderin deposits), red patches, white scarring, or areas of hardened skin around the ankle
- Chronic swelling: Usually worse at the end of the day and may improve overnight, but becomes more persistent over time
- Aching or heaviness: Dull, aching pain in your leg or a burning sensation particularly after standing or walking
- Itchy or tender skin: The area may feel uncomfortable, sensitive to touch, or constantly irritated
- Temperature changes: Areas of skin that feel unusually warm or cold compared to surrounding tissue
Stage 1: Initial ulcer development
The start of a venous ulcer often appears as red and inflamed skin that usually goes undetected because venous ulcers resemble a bug bite, bruise, or mild irritation:
- Small shallow wounds: Small, shallow wounds on the skin with discoloured skin area and itchiness
- Skin breakdown: Initially may look like a minor scrape or persistent sore spot
- Increased sensitivity: The area becomes more tender and prone to injury
- Poor healing: Small cuts or scratches take longer than usual to heal
Active ulcer symptoms
Once an ulcer has formed, typical signs include:
- Open wound location: Usually develops on the inside of the leg, between the knee and the ankle
- Irregular shape: Often shallow, irregularly shaped sores with uneven edges, unlike the round shape of arterial ulcers
- Weeping or discharge: The wound may produce fluid, which can sometimes have an unpleasant smell or appear yellowish
- Surrounding skin changes: The skin surrounding the ulcer may be hard and discoloured with brownish pigmentation or white scarring
- Variable pain levels: This can vary from mild discomfort to severe pain, often worse when the leg is hanging down and improving with elevation
- Size progression: If left untreated, these small sores can grow larger and become more painful, sometimes oozing
When symptoms may worsen
Venous leg ulcer symptoms often follow predictable patterns:
- End of day: Symptoms typically worsen after long periods of standing or sitting due to increased venous pressure
- Hot weather: Heat can cause veins to expand, making symptoms worse and increasing swelling
- Lack of elevation: Symptoms improve when you raise your legs above heart level for 15-30 minutes
- Physical activity: While gentle movement helps circulation, prolonged activity without proper compression support can worsen symptoms
- Dependency position: Pain and throbbing often increase when legs are hanging down
- Weather changes: Some people notice symptoms worsen before storms or with changes in barometric pressure
Causes and risk factors
Primary causes
These ulcers develop due to poor blood flow in the veins, leading to tissue breakdown, especially in the lower extremities. The main underlying causes include:
- Chronic venous insufficiency: When vein valves don't work properly, allowing blood to flow backwards
- Previous blood clots: Deep vein thrombosis can permanently damage vein valves
- Varicose veins: Large, twisted veins that indicate poor venous function
- Congenital vein problems: Some people are born with faulty vein valves or structure
Risk factors you should know
Understanding your personal risk factors can help you take preventive steps and work with your healthcare provider to reduce your chances of developing venous leg ulcers.
Medical conditions that increase risk: Certain health conditions can affect your circulation or wound healing ability, making venous leg ulcers more likely to develop:
- Diabetes – affects circulation and wound healing
- Heart failure – reduces overall circulation
- Kidney disease – can cause fluid retention and swelling
- Arthritis – may limit mobility
- Previous leg fractures or surgery
Lifestyle factors: Your daily habits and work environment can significantly impact your vein health and ulcer risk:
- Prolonged standing or sitting
- Lack of regular exercise
- Being overweight
- Smoking
- Poor nutrition
Other risk factors: Some factors are beyond your control but are important to be aware of when assessing your overall risk:
- Age over 65
- Family history of vein problems
- Female gender (particularly after pregnancy)
- Multiple pregnancies
How venous leg ulcers are diagnosed
Clinical examination
Your doctor will start with a thorough examination of your legs, looking for signs of venous disease such as varicose veins, swelling, skin changes, and the ulcer itself. They'll ask about your symptoms, medical history, and any previous leg problems.
The examination typically includes:
- Checking both legs for comparison
- Assessing the size, depth, and appearance of the ulcer
- Looking for signs of infection
- Testing circulation in your feet
Diagnostic tests
Ankle-Brachial Pressure Index (ABPI): This simple test compares blood pressure in your ankle with that in your arm to check for arterial problems that might affect healing.
Duplex ultrasound scan: This painless scan uses sound waves to create images of blood flow in your leg veins, helping identify problems with vein valves or blockages.
Additional tests may include:
- Blood tests to check for diabetes or other conditions
- Wound swabs if infection is suspected
- Patch testing for allergies if the ulcer isn't healing as expected
Treatment options for venous leg ulcers
Treatment for venous leg ulcers focuses on promoting healing while addressing the underlying vein problems that caused the ulcer. Once your ulcer is healing well, your nurse will see you less often.
Compression therapy
Wear compression stockings or bandages every day as instructed. They help prevent blood from pooling, reduce swelling, help with healing, and reduce pain. After your assessment, you will be placed in the highest strength of compression suitable for you. The type of compression will depend on the size of your wound and whether you are able to independently manage your wound.
Types of compression:
- Compression bandages: Applied by a healthcare professional, these provide consistent pressure to improve blood flow
- Compression stockings: Graduated stockings that you can wear daily
- Compression wraps: Adjustable options for ongoing independent management
Wound care
Managing your venous ulcer starts with proper wound care to support with healing and pain:
- Regular cleaning: Gentle cleansing with saline solution
- Selecting the appropriate dressings: There are a number of dressings that can be applied but the right one is based on the ulcer's condition
- Moisture management: Keeping the wound at the right moisture level to aid healing
- Protection: Preventing further injury to the area by covering it and being more mindful
- Moisturisation: It is essential to keep the skin on the legs well moisturised to maintain good skin condition
Medical treatments
Medications
Depending on the condition of your venous ulcer, a doctor might prescribe medications such as:
- Antibiotics if an infection is present
- Pain relief medications
- Pentoxifylline to improve blood flow (in some cases)
Surgical treatments
- Endovenous procedures to close faulty veins such as varicose veins
- Skin grafts for large or non-healing ulcers
- Surgical debridement (removing of dead tissue) if indication to encourage healing
- If you have a history of DVT, there may be further investigations your vascular specialist will consider
Lifestyle management
There are some things you can be doing on a daily basis to help your wound heal and prevent your venous leg ulcer from getting worse:
- Leg elevation: Raising your legs when resting helps reduce swelling
- Gentle exercise: Walking and ankle exercises improve circulation
- Weight management: Reducing excess weight takes pressure off leg veins
- Proper nutrition: A balanced diet supports wound healing
What to expect during and after treatment
During your treatment
Having a venous leg ulcer can be challenging but understanding what to expect can help you manage the condition more effectively. Treatment typically involves regular visits to a nurse specialist who will clean and dress your wound, monitor healing progress, and adjust your treatment plan as needed.
What you can expect:
- Regular appointments
- Gradual improvement over several weeks or months
- Some discomfort during dressing changes
- Periods where healing seems slow
Supporting your recovery:
- Follow your treatment plan consistently
- Keep appointments even if you feel the ulcer isn't improving
- Report any signs of infection immediately
- Stay as active as possible within your doctor's recommendations
Long-term management
Once you have had a venous leg ulcer, another ulcer could develop within months or years. Therefore, it’s important to focus on long-term management to prevent recurrence and maintain leg health.
Ongoing care includes:
- Regular check-ups with your healthcare team
- Continued use of compression stockings
- Monitoring for early signs of new ulcers
- Managing underlying health conditions
Preventing venous leg ulcers
Daily prevention strategies
You can help reduce your risk of developing a venous leg ulcer in several ways, such as wearing a compression stocking, losing weight and taking care of your skin. If you have any warning signs of a leg ulcer, ask to see a vascular specialist as soon as possible.
Compression stockings: The most effective method of preventing this is to wear compression stockings if you've had an ulcer before or have venous insufficiency.
Leg elevation:
- Raise your legs above heart level when resting
- Use pillows to prop up your legs while sleeping
- Take regular breaks to elevate your legs during the day
Exercise and movement:
- Walk regularly to improve circulation
- Perform ankle exercises, especially if you sit for long periods
- Avoid standing still for extended periods
Skin care:
- Keep your legs clean and moisturised
- Check your skin regularly for changes
- Protect your legs from injury
- Treat any small cuts or scratches promptly
When to seek medical advice
Signs you shouldn't ignore
Seek immediate medical attention if you experience:
- Signs of infection: Redness, increased warmth, or swelling around the wound, or drainage that is yellowish or cloudy
- Rapid deterioration: Sudden increase in ulcer size or depth
- Severe pain: New or worsening pain that doesn't improve with elevation
- Systemic symptoms: Fever, chills, or feeling generally unwell
- Spreading redness: Red streaking extending from the wound up the leg
Having a wound on the leg that takes more than 2 weeks to heal is not normal and is classified as an ulcer. If you are concerned, you should seek specialist advice as soon as possible.
