Leg ulcers are wounds on the lower leg which tend not to heal with treatment and usually occur in patients with poor local blood circulation.

VENOUS ULCERS

Venous ulcers account for 70-80% of all leg ulcers, and will be the main theme of this leaflet, but there are several other types, which require different management, and are discussed later.

Venous ulcers occur when veins are unable to return blood from the leg, which may therefore become swollen and red. A small knock to the leg may then be enough to start the process of ulceration, which is the disintegration of the surface layers of the skin. Venous ulcers usually develop near the calf or ankle, and are typically large, shallow, moist, and relatively painless. They often recur after healing.

INCIDENCE

Venous leg ulcers affect approximately 150,000 people in the UK at any one time, and currently cost the National Health Service £300-400 million each year. It is estimated that 50% of community nurses' time is spent dressing ulcers at home.

Although the chance of developing a leg ulcer increases with age, an ulcer often first appears in middle life and their occurrence before retirement age often leads to loss of work and leisure. Women are almost twice as likely to be affected as men, probably because the pressure in their leg veins, especially during pregnancy, is higher. Common aggravating factors include disease of the veins or arteries, diabetes, smoking, immobility, lack of exercise and obesity.

Prevention

There are many preventative measures for people prone to the formation of venous leg ulcers. These include wearing elastic compression stockings, exercising as much as possible, eating a healthy diet and protecting the legs from injury and extremes of temperature (this includes not sitting too close to a fire). Before the skin breaks down and an ulcer forms, it becomes dark purplish-red and dry. If these warning signs are recognised, the ulcer may be prevented by adequate bandaging. It is important for people with venous ulcers, when they sit or lie down, to raise the legs above the level of the heart to help the blood in the legs circulate. They should also exercise the feet by moving them up and down, as this too will improve their circulation.

CURRENT TREATMENT

The most crucial step is accurate diagnosis of the ulcer type, because current treatment depends on the underlying cause. Usually a simple test can be used to distinguish venous from other types of ulcer. Venous ulcers are treated by using graduated compression to the leg by up to four layers of bandages. The most compression is applied to the ankle, and is gradually reduced up the leg. This aids the return of blood from the leg. Large ulcers may be healed more rapidly by simple skin grafting techniques, and a proportion of patients benefit from surgery to the veins. Trials of drugs thought to help healing have often been inadequate in terms of patient numbers and comparability, but there is a new generation of dressings with the potential to aid healing, and these are currently being tested. In general the outcome of treatment has recently been improved by the use of a more scientific approach to assessment and management.

Other Types of Leg Ulcer

ARTERIAL ULCERS

These form when arteries to the leg are not functioning properly, and fail to deliver adequate supplies of oxygen and nutrients to the tissues. 5-20% of leg ulcers are arterial. They occur typically on the ankle or foot, are usually deeper than venous ulcers and may be very painful, especially at night, or when the leg is raised. Arterial ulcers are often improved by simple non-restrictive bandaging, but may require skin grafting. Patients encouraged to take gentle exercise to improve the circulation.

DIABETIC ULCERS

These usually occur around the ankle or on the foot. Their formation is usually linked to a complication of Diabetes, in which there is loss of feeling in the foot. Diabetics with this complication are less likely to realise that wounds have started in their feet because they cannot feel them.This allows the ulcers to become very deep ; because of high sugar blood sugar levels they are very prone to infection. Prevention is by proper care of the feet and special footwear.

PRESSURE SORES

A pressure sore is a form of ulcer usually over the heel which occurs when pressure is prolonged for several hours on the heel due to immobility of the leg (e.g. following a stroke or a fractured hip). Its prevention is by regular relief of pressure and proper skin care.

The need for more research

Leg ulcers are unpleasant, may be painful, and often lead to social isolation in old people. So far the overall quality of research into the condition has been poor, and has led to inadequate assessment and inappropriate treatment. This has often resulted in ulcers which persist for months or many years, or never heal. Finding out more about the underlying causes of leg ulcers would lead to more effective treatments, and further research has the potential dramatically to improve the rate and quality of healing of ulcers, and so the quality of life of sufferers, as well as saving the NHS many millions of pounds.