AKT · Dermatology/Wounds, ulcers & burns

Venous leg ulcer

Chronic venous hypertension → skin breakdown at the gaiter area

Overview

A chronic leg ulcer from sustained venous hypertension (valvular incompetence). Shallow, exudative ulcers in the GAITER area (medial malleolus), surrounded by the signs of venous disease. The decisive step before treatment is measuring the ankle-brachial pressure index (ABPI) to make compression safe.

Recognise

Shallow, irregular, exudative ulcer over the medial gaiter area (above the medial malleolus)
Surrounding venous skin changes: haemosiderin staining, varicose eczema, lipodermatosclerosis ("inverted champagne bottle" leg), atrophie blanche, oedema
Relatively painless (eased by elevation); pulses present

Red flags

A long-standing non-healing ulcer with rolled/everted edges → consider Marjolin ulcer (SCC in chronic wound) — biopsy; mixed/arterial disease (low ABPI) contraindicates full compression

Differentials & how to tell them apart

Arterial ulcerpunched-out, painful, on the foot/toes/pressure points, ABPI <0.8, absent pulses — compression is harmful here

Neuropathic ulcerpainless, over pressure points (sole/heel), peripheral neuropathy (diabetes), surrounding callus

Marjolin ulcer (SCC)a chronic ulcer that develops rolled, everted, heaped edges — biopsy

Vasculitic/pyoderma gangrenosum ulcerrapidly enlarging, violaceous undermined border, very painful

Clinical image

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Venous leg ulcer — clinical imagesDermNet

Investigations

ANKLE-BRACHIAL PRESSURE INDEX (ABPI) is mandatory before compression: 0.8–1.3 confirms it is safe. Wound assessment/swab only if clinically infected; biopsy a non-healing or atypical ulcer.

Management

Confirm ABPI (0.8–1.3) → graduated compression bandaging + wound care

1Confirm venous aetiology and measure ABPI. If ABPI 0.8–1.3 → graduated compression bandaging (the key intervention) plus simple dressings, emollients and leg elevation.Gate: MEASURE ABPI before compression — significant arterial disease (ABPI <0.8) makes compression dangerous (limb ischaemia), so a low ABPI redirects management to vascular referral, not bandaging
2Optimise healing (nutrition, elevation, exercise); refer for venous intervention (endovenous ablation) to reduce recurrence; biopsy non-healing ulcers; lifelong compression hosiery to prevent recurrence.

Graduated COMPRESSION bandaging/hosiery — the mainstay once ABPI confirms it is safe (0.8–1.3)

Emollients + simple non-adherent dressings — wound bed and surrounding skin; treat varicose eczema

Antibiotics only if clinically infected — not for colonisation/odour alone

Pentoxifylline — adjunct to aid healing in some cases

Key points

ABPI before compression is the safety gate the exam loves. Venous = gaiter, shallow, relatively painless, with venous skin changes; arterial = punched-out, painful, foot, pulseless.

Monitor & prognosis

Healing rate, ABPI, recurrence; surveillance for malignant change.

Heals slowly with compression; high recurrence without ongoing hosiery/venous treatment.

Source: NICE CKS Leg ulcer - venous; SIGN