LEG ULCERS

A leg ulcer - a break in the skin on the lower leg that takes more than 6 weeks to heal - is commonly the result of vascular insufficiency: chronic venous hypertension (a venous ulcer, the most common) or of poor arterial blood supply (an arterial ulcer). Because arterial and venous leg ulcers need different management - compression therapy is dangerous for patients with arterial disease - an important part of leg ulcer assessment is to assess arterial sufficiency by calculating the ankle brachial pressure index (ABPI). ABPI = highest ankle systolic pressure/highest brachial systolic pressure A hand-held Doppler device and a sphygmomanometer and cuff are used to compare ankle and brachial systolic blood pressure.

VENOUS ULCER

Risk factors

• Deep vein thrombosis
• Thrombophlebitis
• Oedematous legs
• Multiple pregnancies
• Varicose veins
• Previous leg ulceration.

Presentation

• Generally in gaiter area
• Exuding, shallow ulcer with diffuse edge
• Associated with some pain
• Staining (pigmentation) of the skin, induration (hardening, ‘woody’ feel), varicose eczema and oedema.
• Atrophie blanche (areas of white skin stippled with red dots)
• ABPI >0.8 on Doppler assessment.

Management aims

• Reduce oedema and pressure in superficial venous system.
• Aid venous return by increasing velocity of flow in deep veins.
• Treat wound according to findings of wound bed.

ARTERIAL ULCER

Risk factors

• Ischaemic heart disease
• Hypertension
• Angina
• Diabetes mellitus
• Intermittent claudication
• Transient ischemic attack
• Myocardial infarction
• Rheumatoid arthritis.

Presentation

• Ulcer generally below ankle
• Dry, deep wound, with 'cliff type' edge
• Dusky-coloured, cold foot
• Pain in lower legs/foot when raised
• Loss of hair on legs
• Atrophic shiny skin on shin
• Thickened toe nails
• Loss of pedal pulses 
• ABPI <0.6.

Management aims

• Treat symptoms.
• Treat wound according to assessment of wound bed.
• Reduce the risk of infection.
• If ABPI <0.5, urgent referral to vascular surgeon recommended.

MIXED ULCER (elements of venous and arterial disease)

Presentation

• Venous problems and arterial insufficiency
• ABPI 0.6-0.8 on Doppler assessment

Management aims

• Reduce symptoms
• Treat wound according to assessment of wound bed.