This website is intended for UK healthcare professionals only
User log in




Trial log in
  

ULCERS, SKIN

Most skin leg ulcers are the result of venous or arterial disease causing vascular insufficiency (leg ulcers), pressure (decubitus ulcers or bedsores), neuropathy (e.g. diabetic foot ulcers) or some combination of these. Ulcerated skin lesions are also seen in collagen-vascular diseases, e.g. rheumatoid arthritis, and other disorders such as inflammatory bowel disease. A chronic leg ulcer associated with venous insufficiency is the type of ulcer most often seen in clinical practice.

VENOUS (GRAVITATIONAL) LEG ULCERS

Faulty valves in the veins allow pooling of blood, which increases the venous pressure. Fibrin deposits form around the capillaries and oxygen and nutrient supplies are reduced. The area is swollen. Weeping painless (unless infected) ulcers may be triggered by injury, deep vein thrombosis (DVT), hypertension, obesity, prolonged standing or surgery to the leg. Venous ulcers are usually shallow. The surrounding skin is often dry and itchy. Venous ulcers often occur in the gaiter area close to the malleoli and may be accompanied by skin scaling and brown (haemosiderin) pigmentation. See also Wounds and wound care

ARTERIAL LEG ULCERS

Generally are associated with atherosclerosis and poor or reduced circulation. More common in individuals presenting with hypertension, CHD, obesity, hyperlipidaemia and smokers. These painful ulcers appear often on feet, heels and toes. A typical punched out appearance of the edges are present. Peripheral pulses may be absent. See also Wounds and wound care

NEUROPATHIC LEG ULCERS

Neuopathy from whatever cause may lead to ulcer formation on the lower limbs.

DIABETIC LEG ULCERS

Often deep, may be painless. Infection is common. Risk factors: • peripheral neuropathy • peripheral arterial disease/ischaemia • poor glycaemic control • foot deformities.

LEG ULCER REFERRAL INDICATIONS

Before treatment

  • Uncertain diagnosis.
  • Suspected alternative (non-venous) cause of ulceration, e.g. arterial or mixed venous/arterial ulcer. Refer for assessment of arterial disease if ABPI <0.8, urgently to vascular surgeon if ABPI <0.5.
  • Ulcer malignant, or deteriorating rapidly. Ulcers of atypical appearance or distribution may require biopsy by dermatology.
  • Rheumatoid ulcer, or ulcers associated with systemic vasculitis.
  • Diabetic ulcer, or newly diagnosed diabetes in a person with an ulcer.

During treatment

  • Complication related to the ulcer or treatment:
  • Contact dermatitis (refer to a dermatologist for patch testing).
  • Cellulitis requiring intravenous antibiotics or worsening with treatment.
  • Uncontrolled pain (refer to specialist pain team).
  • Ulcer unhealed or worsening ulcer after 2–3 months of standard treatment.
  • Recurring ulcers.
  • Conditions needing specialist intervention, e.g. varicose veins, arterial insufficiency

DermNet NZ. Leg ulcer https://dermnetnz.org/topics/leg-ulcer/

NICE CKS. Leg ulcer - venous; updated 2021. https://cks.nice.org.uk/topics/leg-ulcer-venous/

 

Practice Nurse featured articles

Healing wounds: where can it go wrong? Elizabeth Merlin-Manton

Wound care: selecting the right dressings Elizabeth Merlin-Manton

New to general practice nursing? Practice nurse skills: Part 2. Katherine Hunt

Return to index