Venous leg ulcers

Management of wounds in the NHS has been reported to have a significant cost and resource burden on the increasingly stretched health system. Management of venous leg ulcers is the most time-consuming medical care for patients with wounds in primary care settings (Guest et al, 2020).

Venous leg ulcers are estimated to affect 1 in 500 people in the UK, and incidences are expected to increase with older age. It is estimated that approximately 1 in 50 people over the age of 80 years will have a venous leg ulcer (NHS, 2022).

‘A leg ulcer is a break in the skin below the knee which has not healed within 2 weeks’ (National Clinical Guideline Centre, 2013). A venous leg ulcer occurs in the presence of venous disease and is the most common type of leg ulcer (National Clinical Guideline Centre, 2013).

Leg ulcers are ‘lower limb wounds below the knee and above the ankle’ (National Wound Care Strategy Programme, 2020).

• Varicose veins – check by assessing the whole leg up to the groin, while the patient is standing.
• Varicose eczema – usually noted if patients have high blood pressure, varicose veins, a clinical history of deep vein thrombosis (a blood clot in the leg vein), phlebitis (inflammation of the vein wall) or cellulitis (infection in the skin).
• Venous oedema – swelling (can be unilateral) of the lower limb that tends to be pitting and reduces when the patient elevates their legs at night. This should not be confused with cardiac or renal oedema, which are also pitting but will always affect both legs.
• Ankle flare – tiny varicose veins noted on the inner aspect of the ankle.
• Atrophy blanche – venous congestion causing swollen congested capillaries, sometimes visible as tiny red dots under the skin. Where the capillaries cannot sustain this pressure, they atrophy, leaving white lacy areas of avascular tissue.
• Haemosiderin staining – a red/brown

The cause of venous leg ulcers is thought to be the result of a combination of chronic venous hypertension resulting from venous incompetence and calf muscle insufficiency. It is characterised by induration (thickening and hardening of soft tissue), haemosiderin deposition, fibrosis and reticulate scarring (atrophy blanche) collectively known as lipodermatosclerosis (Primary Care Dermatology Society, 2022).

A primary factor that contributes to the onset of a venous leg ulcer is damage to the valve(s) in the vein (as a result of a patient’s lifestyle, e.g. pregnancy, employment, trauma) with resultant venous reflux (Figure 2). Reflux results in high pressure in the dermal capillary bed, which, if not reduced, leads to damage of a patient’s micro-circulation.

Assessment of a patient with a suspected venous leg ulcer should be undertaken using a holistic framework within 14 days of initial presentation. Assessment should include clinical and psychosocial needs, a review of the patient’s current medication, any reported pain and appropriate analgesia needs, the presence of any possible infection and nutrition (National Wound Care Strategy Programme, 2020).

People with leg wounds may only seek clinical advice when healing is delayed, or they become aware that their wound is not healing (National Wound Care Strategy Programme, 2020). A multidisciplinary team approach to care is essential. This may include clinicians from podiatry, nursing, medicine, tissue viability, vascular, lymphoedema and dermatology services as clinically dictated.

To assess for diagnosis of a venous leg ulcer and exclude any arterial involvement, a lower limb assessment should be undertaken that includes one of the investigations identified in table 1, a neuropathic assessment to check sensation and

Immediate care should include assessment (within a holistic framework) of the wound bed and surrounding skin. Peri-wound and limb skin cleansing and an emollient should be undertaken or offered (The Scottish Intercollegiate Guidelines Network, 2010). For wounds on the leg and/or suspected venous leg ulcers, first-line mild graduated compression should be applied (British Lymphology Society, 2019). Compression systems can be used in conjunction with an appropriate interactive wound-management dressing, which should be further documented in a comprehensive wound assessment. When appropriate, people with leg and foot wounds should be given relevant advice on self-care (Collier, 2020).

If any wound infection is suspected or confirmed, patients should be informed who they can contact to discuss treatment options. Clinicians should refer to NICE Guidelines (NICE, 2020) and local policies for infection and antimicrobial stewardship.

References

British Lymphology Society. Assessing vascular status in the presence of chronic oedema prior to the application of compression hosiery: Position Document to guide decision making. 2019. https://www.thebls.com/public/uploads/documents/document-95871580220184.pdf (accessed 29 March 2023)

Browse NL, Burnand KG. The cause of venous ulceration. Lancet. 1982;2(8292):243-245. https://doi.org/10.1016/s0140-6736(82)90325-7

Chant A. Tissue pressure, posture, and venous ulceration. Lancet. 1990;336(8722):1050-1051. https://doi.org/10.1016/0140-6736(90)92503-a

Coleridge Smith PD, Thomas P et al. Causes of venous ulceration: a new hypothesis. Br Med J (Clin Res Ed). 1988;296(6638):1726-1727. https://doi.org/10.1136/bmj.296.6638.1726

Collier M. Self-care in the community. Br J Community Nurs. 2020;25(Sup6):S5. https://doi.org/10.12968/bjcn.2020.25.Sup6.S5

Guest JF, Fuller GW, Vowden P. Cohort study evaluating the burden of wounds to the UK's National Health Service in 2017/2018: update from 2012/2013. BMJ Open. 2020;10(12):e045253. https://doi.org/10.1136/bmjopen-2020-045253

Herrick