1. What is a leg ulcer?

A leg ulcer is simply a break in the skin of the leg. The immediate cause is usually an injury, often a minor one that breaks the skin. In most people such an injury will heal up without difficulty within a week or two. However, if there is an underlying problem the skin does not heal and the area of breakdown may even increase in size. This is a chronic leg ulcer. Leg ulcers tend to affect older people and are more common in women.

2. What causes leg ulcers?

Venous ulcers – these make up about 70% of all ulcers.  Every time your leg muscles move they help pump the blood up to the heart, whilst a series of one-way valves stop it from flowing backwards.  If these valves become damaged, due to an injury, deep vein thrombosis (DVT), multiple pregnancies etc., the blood will flow back down the leg and cause increased pressure on the veins.  After a time, the veins will become stretched and fluid will leak out causing swelling of the legs, thickening and damage to the skin.
Arterial ulcers – About 10% of people have this type.  The arteries supply blood to the legs and feet.  If the arteries become narrowed (atherosclerosis), due to smoking, high blood pressure, diabetes, rheumatoid arthritis, heart disease etc., the leg circulation will be reduced, the leg will be starved of oxygen and nutrients and the skin will begin to break down.
Diabetic ulcers – 5% of diabetics will suffer with ulcers, usually on the foot.  Diabetes increases the likelihood of atherosclerosis.  It also affects the nerves, causing a lack of sensation in the feet (sensory neuropathy) which makes ulcers more likely to appear.  Diabetic ulcers can occur due to smoking, poor dietary control, incorrect medication, poor foot care or badly fitting shoes.
Your doctor will examine you and do some tests to see what sort of ulcer you have.

3. What are the symptoms?

Venous ulcers – The appearance of a venous leg ulcer is fairly typical.  It is often located just above the ankle, on the inside of the leg. The leg is swollen and tender to touch and the skin may feel dry and itchy (varicose eczema) with mottled brown or black staining.  Some ulcers are painful, particularly if they become infected.
Arterial ulcers – These tend to occur on the foot and lower part of the leg.  The feet and legs often feel cold and may have a whitish or bluish, shiny appearance.  Arterial leg ulcers are often painful, particularly at night in bed.  The pain is often relieved when the legs are lowered.

4. How are leg ulcers diagnosed?

Diagnosis is usually made on the basis of the appearance and location of the ulcer and your doctor or nurse should carry out a thorough examination and assessment of your condition.  These checks are important because the treatment for venous and arterial ulcers is different and they must be sure what type of ulcer you have.  To rule out poor circulation as a cause, it is usual to compare the blood pressure in the ankle with that in the arm to give a ratio known as the Ankle Brachial Pressure Index, or ABPI. This is measured using a hand held ultrasound machine called a Doppler. Routine blood and urine tests may also be done to check for other causes such as anaemia and diabetes.  Venous and arterial ulcers can be further investigated by means of an ultrasound, or Duplex, scan. Arterial ulcers may require further investigation with an arteriogram (x-ray of the blood vessels).

5. How will I be treated?

Treatment of a venous leg ulcer is aimed firstly at controlling the high pressure in the leg veins and secondly at the ulcer itself. The mainstays of treatment are compression bandaging or stockings and elevation of the limb:

Elevation of the limb. The higher the leg, the lower the pressure in the leg veins. If the foot is elevated above the heart then the pressure in the foot drops to a normal level. Put your legs up whenever you can and as high as you are able. Elevate the lower end of your bed (6 inches or so) so that when in bed your feet are a little higher than your head.
Compression bandaging or stockings. In order to keep the pressure in the leg veins at the ankle low when you are standing up, you will be treated with compression bandaging or stockings. Several layers of bandages may be required to get the necessary pressure to control the veins. Once the ulcer is healed, compression stockings are usually necessary to prevent the ulcer from returning. These stockings need to be specially fitted and are much stronger than ordinary "support tights". If you have difficulty putting on your stockings then you can buy a special stocking applicator.
Dressings. The nurse will use a number of different dressings under the bandages depending on the state of the ulcer itself. These dressings may well change as the ulcer progresses.
Surgery. Occasionally either a skin graft or an operation on the veins may be necessary. If your ulcer is due to varicose veins then these may be treated, usually once the ulcer has healed.
Arterial ulcers may benefit from surgery – the insertion of new leg arteries (bypass operation) or balloon angioplasty (stretching an artery with a balloon), a procedure that relieves narrowing and obstruction of the arteries. 
Antibiotics are occasionally required to treat ulcers, particularly if there is evidence of infection in the surrounding tissues and skin (cellulitis) or lymphatic channels (lymphangitis).

6. How long will it take the ulcer to heal?

It has usually taken many years for the venous disease to cause the ulcers, so it is not surprising that the ulcers may take a fairly long time to heal. Although most venous ulcers will heal up in 3-4 months, a small proportion will take considerably longer. Even in these resistant cases treatment is usually successful.
Mixed arterial and venous ulcers are more difficult to treat and in the more severe cases it may not be possible to achieve healing. 

7. Is there any risk of me losing my leg?

Venous ulcers It is very rare indeed for venous ulceration of the leg to lead to a requirement for amputation of the leg and even the larger ulcers can usually be treated successfully.
Arterial ulcers Occasionally it is not possible to insert a new artery in your leg or to perform an angioplasty and if you have a very large painful ulcer on your leg it may be better for you to consider an amputation. Your doctor will discuss this with you in detail. He or she will be aware that this is a very difficult decision for you and will not proceed with an amputation unless you are happy that this is the appropriate option for you.

8. How can I help myself?

• Stop smoking.  This is one of the major risk factors for vascular (circulatory) disease.  It is difficult to give up but help is available. Speak to your doctor or call the NHS Smoking Helpline on 0800 169 0169.
• Take regular exercise.  Using your foot and leg muscles encourages the circulation and also helps you control your weight.  Avoid standing or sitting in one position for a long time.  Walk about as much as possible or just move your feet round and up and down.
• Eat a healthy diet.  Include protein, oily fish, fresh fruit and vegetables in your diet or speak to your doctor or dietician for advice.  Vitamins A, C and E (the antioxidants) are thought to be beneficial to the circulation.
• If you are advised to put your legs up, ideally rest with your ankles above waist height.  Don’t cross your legs when sitting or allow the edge of the chair to press into the back of your legs.
• Wear support stockings if these have been advised.  If you have a problem with your dressings or bandages, or if your stockings become loose, tell your nurse straight away.
• Avoid tight clothing on your legs and wear comfortable, well-fitting shoes.  See a chiropodist regularly (at least every 3 months) and take care when cutting toe nails.
• Protect your skin and legs.  Keep your feet and legs warm but avoid extremes of temperature, e.g. hot baths, sunburn, sitting too close to the fire.  Use mild soap, or soap substitute, to keep your skin clean and keep it supple with a bland moisturiser.  Your doctor or nurse can advise you about products to use.  Take care not to bang your feet or legs on sharp corners or objects.
• Inspect your feet and legs regularly.  Look for sores or changes in colour – use a mirror to help.  Do not delay in seeking help if you think you are developing an ulcer.

9. How can I stop the ulcer coming back?

Ulcers do have a tendency to recur, especially in elderly people. Although the skin is intact the underlying problem with the veins remains and you must take precautions to prevent the ulcer recurring. If you have been advised to wear support stockings, you will need to wear these indefinitely.  These should be replaced about every six months to maintain adequate compression.