Venous leg ulcers: healing the wound and treating the vein behind it

Why venous ulcers form near the ankle

Your leg veins carry blood back up toward the heart, helped by one-way valves and by the squeeze of your calf muscles when you walk. When the valves leak (reflux) or a vein is blocked, pressure builds in the lower leg. This venous hypertension is thought to be the main reason these ulcers form, and a weak calf-muscle pump adds to it.⁠^[1]

Pressure and inflammation slowly damage the skin until an ulcer opens. Venous ulcers commonly sit in the “gaiter area” over the inner ankle bone. They tend to be shallow, with an irregular shape and clear edges.⁠^[1]

Swipe sideways to see the whole drawing.

Ulcers from poor arterial circulation are usually deeper and sit on the front of the leg, the top of the foot or the toes; ulcers from diabetic nerve damage usually form on the sole over a bony spot, ringed by callus.⁠^[1] For a sore on the bottom of the foot, read about diabetic foot ulcers. If blood flow is the worry, see peripheral artery disease or the signs of poor circulation in the feet (external site).

Who gets them, and the signs to watch for

Risk factors include being 55 or older, a family history of vein problems, a higher body weight, a past blood clot in a leg or lung, several pregnancies, an inactive lifestyle and a previous ulcer. Long hours of standing or sitting are also linked to leaky veins.⁠^[1]

Signs that point to vein trouble:

• a heavy, aching or itchy leg, with swelling that builds through the day and eases when you put your feet up
• varicose veins, or small swollen veins around the ankle
• skin above the ankle that turns darker, red or hard, sometimes leaving the lower leg shaped like an upside-down bottle
• white, scar-like patches of skin⁠^[1]

How a leg ulcer is evaluated

Dr. Efe Ozturk, a Foot and Ankle Surgeon who is board certified in wound care (FAPWH), treats venous leg ulcers with compression and wound care. He measures the ulcer, asks about past blood clots and ulcers, and examines the whole leg.

The workup usually includes:

• Arterial blood flow, first. Pulses and the ankle-brachial index (ankle blood pressure compared with the arm) are recommended for everyone with a suspected venous ulcer, plus an arterial ultrasound if the index is abnormal or diabetes or kidney disease may have hardened the arteries.⁠^[1] We do noninvasive circulation testing at our practice; vascular specialists do more detailed arterial imaging when it’s needed. See circulation tests for foot wounds.
• A vein ultrasound (duplex scan) to look for reflux and blockage in the surface and deep veins.⁠^[1] We arrange this scan.
• A biopsy if healing stalls or the ulcer looks unusual. Of long-lasting ulcers that don’t respond to vascular treatment, 20–23% may have another cause, such as vasculitis; skin cancer is also a known complication.⁠^[1]

Compression: the foundation of healing

Compression squeezes the lower leg to help blood flow back toward the heart, aiming to ease swelling and pain and help the ulcer heal.⁠^[3,1] A Cochrane review of 48 randomized trials, most of them small, found that compression heals more ulcers than none, multi-layer systems work better than a single bandage, and systems with an elastic bandage appear to work better than mostly non-stretch ones.⁠^[3] Elastic wraps usually need changing only about once a week.⁠^[1] Once blood flow is confirmed, compression is the center of your care with us.

Compression isn’t safe with significant arterial disease or uncontrolled heart failure; drainage, discomfort and trouble putting wraps on can also get in the way.⁠^[1]

Alongside compression:

• Cleaning the wound. Removing dead tissue (debridement) may help a venous ulcer heal.⁠^[1] We do this in the office when the wound needs it. See wound debridement and what happens at wound care visits.
• Dressings cover the wound and keep it moist; no one type has been shown to beat the others under good compression.⁠^[1]
• Staying active. Strengthening exercises plus prescribed physical activity may help more ulcers heal.⁠^[1]
• Medicines. Pentoxifylline, a prescription tablet, improved healing in trials; it can cause nausea, stomach upset, headache or dizziness. Antibiotics are reserved for an ulcer that is infected.⁠^[1]

Treating the vein: the procedure that speeds healing

Compression helps ulcers heal, but it doesn’t treat the leaky vein causing the high pressure.⁠^[2] Endovenous ablation treats that faulty surface vein from the inside, and a large trial supports doing it early.⁠^[2]

• Faster healing. In the EVRA trial, 450 people with a venous leg ulcer and a leaky surface vein all wore compression. Half were assigned to ablation within two weeks; for the rest, it was deferred until the ulcer healed or six months passed. With early ablation, ulcers healed in a median of 56 days versus 82, and 85.6% versus 76.3% had healed by 24 weeks.⁠^[2]
• Fewer returns. Longer follow-up of the same trial found ulcers came back less often overall after early ablation (0.11 versus 0.16 recurrences per person-year), though the time until a first recurrence wasn’t clearly different.⁠^[5] In an earlier trial of 500 people, adding vein surgery to compression didn’t change healing, but at four years ulcers had returned in 31% of the surgery group versus 56% with compression alone.⁠^[4]
• Often correctable. In a US registry of people seen at vein centers, 97% of those with a venous ulcer had vein disease that a procedure could correct.⁠^[6]

Vein procedures are done by vascular and vein specialists; we refer you and keep your wound care going while the vein is treated. In EVRA, the most common problems after ablation were pain and deep-vein thrombosis (a blood clot).⁠^[2]

When an ulcer won’t close: grafts and skin substitutes

Most venous ulcers heal with compression.⁠^[7] If one hasn’t improved after four weeks of good standard care, added treatments should be considered.⁠^[1] In a Cochrane review of 17 trials, bilayer artificial skin used together with compression healed more venous ulcers than a simple dressing with compression; other graft types lacked enough evidence.⁠^[8] For a very large ulcer (larger than 25 square centimeters, or about 4 square inches), healing is unlikely without a graft, so grafting can be considered as the first treatment.⁠^[1] For the wounds that need it, we offer skin substitutes and skin grafts, used together with compression.

Hyperbaric oxygen isn’t recommended for venous ulcers, and a wound VAC (negative-pressure wound therapy) isn’t a first-line treatment for them.⁠^[1]

Keeping the ulcer from coming back

Recurrence rates as high as 70% have been reported.⁠^[1] Because so many ulcers return, guidelines recommend staying in compression after the ulcer heals.⁠^[7]

• Stockings, long term. Stockings of 30–40 mm Hg are preferred (at least 20–30 mm Hg). They come off at night and should be replaced about every six months, because washing wears down the squeeze.⁠^[1]
• A stocking you will wear. Firmer stockings may prevent more ulcers, but people may be less likely to keep wearing them.⁠^[7]
• Treating the vein, which lowers the chance of a new ulcer.⁠^[4,5]
• Moving and resting well. Exercise helps your calf-muscle pump work better, and raising your legs while wearing stockings can help.⁠^[1]

When to seek care

See us within a day or two for any leg or foot wound that isn’t healing, especially if you have diabetes. Call us the same day if the skin around the ulcer becomes newly red, warm or more swollen, or the ulcer suddenly hurts more; these can be signs of infection, which needs treatment.⁠^[1] If you have diabetes or poor circulation, also call the same day for a red, hot, swollen foot or new foot pain at night or at rest.