Venous Leg Ulcers

Overview

Venous leg ulcers are open wounds on the lower leg that arise from chronically elevated pressure in the veins of the leg (venous hypertension), most commonly due to incompetent (leaking) valves in the superficial or deep venous system. They are the most common type of leg ulcer, accounting for the large majority of chronic lower limb ulceration seen in general practice, wound clinics and vascular surgery. Unlike simple wounds, venous ulcers are a manifestation of underlying chronic venous disease and rarely heal permanently unless the underlying venous abnormality is identified and treated.

Prevalence

Chronic venous disease is extremely common, affecting a substantial proportion of the adult population, with visible varicose veins present in around a fifth to a third of adults and more advanced skin changes in a smaller subset. Venous leg ulcers specifically affect roughly 1% of adults at some point in their lives, with prevalence rising sharply with age. Active ulceration is seen in approximately 1 to 3% of people over 65. Venous disease is responsible for 60 to 80% of all chronic leg ulcers, making it far more common than arterial, diabetic or mixed-aetiology ulcers.

Risk factors include increasing age, female sex, obesity, prolonged standing occupations, previous deep vein thrombosis (DVT), family history of varicose veins, multiple pregnancies, and previous leg trauma or fracture. Venous ulcers have a significant tendency to recur. Up to 70% recur within five years without adequate treatment of the underlying venous incompetence, making correct diagnosis and definitive management essential rather than optimistic wound dressing alone.

Causes

Venous ulceration develops through a common final pathway of venous hypertension: sustained elevation of pressure within the venous system of the leg, particularly during standing and walking when pressure should normally fall due to the calf muscle pump. The mechanisms behind this include:

• Superficial venous reflux: incompetence of the great or small saphenous veins, or their major tributaries, allowing blood to reflux downward instead of being returned to the heart. This is the single most common and most treatable cause.
• Deep venous reflux or obstruction: valve failure in the femoral or popliteal veins, or obstruction from previous DVT (post-thrombotic syndrome), which is harder to correct but still amenable to some interventions.
• Perforator vein incompetence: failed one-way valves in the small veins connecting superficial and deep systems, allowing high pressure to be transmitted directly to the skin and subcutaneous tissue.
• Calf muscle pump failure: reduced ankle mobility, immobility or neuromuscular disease reducing the effectiveness of the calf as a venous pump.
• Pelvic venous disease: reflux from incompetent ovarian or internal iliac veins, or iliac vein compression (May-Thurner syndrome), can contribute to lower limb venous hypertension, particularly in women, and is often under-recognised as a driver of atypical or recurrent venous ulceration.

Sustained venous hypertension leads to capillary damage, leakage of fibrinogen and red cell breakdown products into the tissue, chronic inflammation, and progressive skin and subcutaneous fibrosis (lipodermatosclerosis). This fragile, poorly nourished skin eventually breaks down, often after minor trauma, to form an ulcer that fails to heal because the driving venous hypertension persists.

Signs and Symptoms

Venous ulcers typically occur over the medial gaiter area of the lower leg (the region above the inner ankle bone), though lateral and less commonly circumferential ulcers occur. Typical features include:

• Irregular but shallow ulcer edges, with a moist, granulating or fibrinous base
• Surrounding haemosiderin staining (brownish skin discolouration from chronic red cell breakdown)
• Lipodermatosclerosis: firm, woody induration and narrowing of the lower calf (an “inverted champagne bottle” leg shape)
• Atrophie blanche: pale, scarred, star-shaped areas of skin
• Venous eczema (varicose eczema) with itching, scaling and weeping skin
• Visible varicose veins or telangiectasia
• Ankle and lower leg swelling, worse at the end of the day and improved with elevation
• Aching, heaviness or cramping in the leg, typically relieved by elevation and worsened by prolonged standing
• Pulses are usually palpable and normal (an important distinguishing feature from arterial ulcers) unless there is coexisting peripheral arterial disease

Pain is often present but is typically less severe than in arterial ulcers, and characteristically improves with leg elevation, the opposite pattern to arterial disease, where elevation worsens pain.

What venous ulcers look like

The images below show real examples of venous ulcers and the skin changes that accompany them, from active ulceration through to healed scarring. Click any image to view it at full size.

Complications of Untreated Venous Ulcers

Leaving venous ulcers untreated, or managing them with wound dressings alone without addressing the underlying venous hypertension, carries significant risks:

• Chronic non-healing and recurrence: ulcers may persist for months to years, or heal and recur repeatedly, without correction of venous reflux.
• Infection: cellulitis, spreading soft tissue infection and, in severe cases, osteomyelitis of underlying bone.
• Increasing wound size and depth, occasionally exposing tendon or bone.
• Malignant transformation (Marjolin’s ulcer): squamous cell carcinoma arising within a chronic, long-standing ulcer, an uncommon but serious complication requiring biopsy of any atypical or non-healing ulcer edge.
• Progressive lipodermatosclerosis and limb fibrosis, causing permanent leg shape change and reduced mobility.
• Significant impact on quality of life: chronic pain, exudate, odour, impaired mobility, sleep disturbance, social isolation and depression are well documented in patients with long-standing venous ulcers.
• Substantial healthcare and economic burden: chronic wound care, dressings and nursing visits over years, with associated costs to the patient and health system.
• Sepsis, in severe or neglected infected ulcers, occasionally requiring hospitalisation.

Early, correct diagnosis and treatment of the underlying venous abnormality, rather than ulcer dressings in isolation, is central to preventing these outcomes.

Assessment and Management at Perth Vascular Clinic

Perth Vascular Clinic offers a comprehensive, structured pathway for the assessment and treatment of venous leg ulcers, combining specialist vascular surgical expertise with in-house diagnostic imaging and the full range of modern conservative, endovenous and surgical treatment options.

Comprehensive assessment

• Specialist vascular consultation with a fellowship-trained vascular and endovascular surgeon, including a detailed history and examination of the ulcer, leg and vascular system.
• In-house diagnostic vascular ultrasound, including duplex mapping of the superficial, deep and perforator venous systems to precisely identify the source and extent of venous reflux or obstruction.
• Ankle-brachial pressure index (ABPI) and arterial assessment in our ABI Clinic, to safely exclude or identify coexisting arterial disease before compression therapy is commenced.
• CEAP staging of chronic venous disease to guide and document treatment planning.
• Assessment for pelvic venous contributors to lower limb venous disease in appropriate patients, including referral for pelvic venous imaging where indicated.
• Wound assessment, including biopsy referral where an atypical or non-healing ulcer raises concern for an alternative diagnosis.

Management options

Perth Vascular Clinic provides the full spectrum of modern venous ulcer management under one roof, tailored to each patient’s individual venous anatomy and general health:

• Conservative therapy: supervised compression bandaging and stockings through our Compression Stockings Clinic, wound care advice, and coordination with wound care nursing and community services.
• Endovenous ablation: radiofrequency ablation (RFA), endovenous laser ablation and other minimally invasive techniques to close incompetent superficial veins under local anaesthetic, as an office-based procedure.
• Ultrasound-guided foam sclerotherapy for residual varicosities and perforator incompetence.
• Open venous surgery, including saphenous vein ligation and stripping, for selected patients where this remains the most appropriate option.
• Iliac vein stenting for patients with significant iliac venous outflow obstruction contributing to non-healing or recurrent ulceration.
• Ovarian and internal iliac vein embolisation for patients in whom pelvic venous reflux is contributing to lower limb venous disease.
• Coordinated multidisciplinary care, liaising with GPs, wound care nurses and other specialists to optimise healing and prevent recurrence.
• Structured follow-up, including surveillance duplex ultrasound, to confirm treatment success and monitor for recurrence.

Patients can be referred to Perth Vascular Clinic for assessment of a non-healing, recurrent or newly diagnosed venous leg ulcer, or for any concerning leg wound where the underlying cause is uncertain.

This information is provided for general educational purposes and does not replace individual medical assessment. Please consult your GP or a vascular specialist for advice specific to your circumstances.