Venous Skin Ulcer

Topic Overview

What is a venous skin ulcer?

A skin ulcer is a type of wound that develops on the skin. A venous skin ulcer is a shallow wound that develops when the leg veins don't return blood back toward the heart as they normally would (venous insufficiency).

These ulcers usually develop on the sides of the lower leg, above the ankle and below the calf. See a picture of areas affected by venous skin ulcers.

Venous skin ulcers are slow to heal and often come back if you don't take steps to prevent them.

A venous skin ulcer also is called a stasis leg ulcer.

What causes venous skin ulcers?

Your veins have one-way valves that keep blood flowing toward the heart. In venous insufficiency, the valves are damaged, and blood backs up and pools in the vein. The blood may leak out of the vein and into the surrounding tissue. This can lead to a breakdown of the tissue and an ulcer.

See a picture of abnormal blood flow caused by venous insufficiency.

Veins that become blocked also may cause blood to pool, leading to these ulcers.

What are the symptoms?

The first sign of a venous skin ulcer is skin that turns dark red or purple over the area where the blood is leaking out of the vein. The skin also may become thick, dry, and itchy.

Without treatment, an ulcer may form. The ulcer may be painful. You also may have swollen and achy legs.

If the wound becomes infected, the infection may cause an odor, and pus may drain from the wound. The area around the wound also may be more tender and red.

Call your doctor when you first notice the signs of a venous skin ulcer, because you may be able to prevent the ulcer from forming. If an ulcer has formed, get treatment right away, because new and smaller ulcers tend to heal faster than larger ones.

How are venous skin ulcers diagnosed?

Your doctor will diagnose venous skin ulcers by asking questions about your health and looking at your legs. Your doctor may also use duplex Doppler ultrasound. This test shows how well blood is moving through the lower leg.

Your doctor may use other tests to check for problems related to venous skin ulcers or to recheck the ulcer if it does not heal within a few weeks after starting treatment.

How are they treated?

Better blood circulation helps prevent and treat venous skin ulcers. To improve your blood circulation, you can:

  • Lift your legs above the level of your heart as often as possible. For example, lie down and then prop your legs up with pillows.
  • Use compression stockings or bandages. These help prevent blood from pooling in your legs.
  • Walk daily. Walking helps your blood circulation.

After your ulcer has healed, continue to wear compression stockings. Take them off only when you bathe and sleep. Compression therapy helps your blood circulate and helps prevent other ulcers from forming.

What makes venous skin ulcers more likely?

Risk factors are things that make a health problem more likely. Risk factors for venous insufficiency and venous skin ulcers include:

  • Deep vein thrombosis , in which a blood clot (thrombus) forms in the deep veins of the legs.
  • Obesity .
  • Pregnancies, which may make a vein problem worse.
  • A family history of varicose veins.

Smoking, lack of physical activity, excessive alcohol use, aging, poor nutrition (especially not getting enough protein), and work that requires many hours of standing increase your risk for venous skin ulcers even more.

Venous skin ulcers affect millions of people worldwide. They are more common in older people.

Frequently Asked Questions

Learning about venous skin ulcers:

Being diagnosed:

Getting treatment:

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  Venous skin ulcers: Using compression stockings

Symptoms

Venous skin ulcers typically develop on the inside of the lower leg, above the ankle bone and below the calf. Less frequently, they develop on the outside of the lower leg. See a picture of areas affected by venous skin ulcers.

The first sign of a skin ulcer is the appearance of dark red or purple skin over the affected area. It may also become thickened and dry and itchy. Contact your doctor if you have any of these warning signs.

Without treatment, an open wound (ulcer) may form. Venous skin ulcers often weep clear fluid and are covered with a yellowish film. The ulcer's edge is typically ragged, and the skin around it often thickens and turns reddish brown in color. You may also have:

  • Pain, although it is not always present.
  • Swelling and aches in the legs that are worse at the end of the day and when standing and are relieved when the legs are elevated above the level of the heart.
  • Sensitized skin. The skin around the affected area becomes susceptible to rashes from topical medicines, perfumes, and other ingredients in creams and lotions.

Because venous skin ulcers are a result of poor circulation, these wounds are often slow to heal. Contact your doctor when you first notice the signs of a venous ulcer, because you may be able to prevent an ulcer from forming. If an ulcer has already formed, get immediate treatment because smaller ulcers that have not been present long tend to heal faster than larger ones.

If an ulcer becomes infected, there may be an odor, pus draining from the wound, and increased tenderness and redness. Call your doctor if you have signs of infection.

Exams and Tests

It is important to know whether a leg ulcer is a venous skin ulcer or another type of skin ulcer before deciding which treatment is appropriate. Compression stockings, the primary treatment for venous skin ulcers, will make an arterial ulcer worse.

Skin ulcer type can usually be diagnosed with a health history and physical exam. Your doctor may also use duplex Doppler ultrasound to confirm whether and where venous insufficiency is playing a part in ulcer formation.

Additional testing to check for other conditions that can be related to a skin ulcer includes:

If you have a venous skin ulcer that has not healed after a few weeks of wearing compression stockings and elevating your legs, your doctor may do a:

Treatment Overview

The key to treating venous skin ulcers is using compression stockings and elevating your legs. Compression reverses the circulation problem in the legs and helps control painful swelling from fluid buildup (edema). People who stick to a long-term compression treatment regimen have much greater treatment success than those who do not. Also, continuing compression after healing may prevent ulcers from coming back.

See a picture of how to put on compression stockings.

Prevention

If you are at risk of developing a venous skin ulcer or have had one before, wear compression stockings during your waking hours and try to elevate your legs as often as possible.

Compression stockings are also important if you have had a deep vein thrombosis, or blood clot. Below-the-knee compression stockings may lower the risk of postthrombotic syndrome, including venous skin ulcers.

For more information, see:

Click here to view an Actionset. Venous skin ulcers: Using compression stockings.

If you have poor blood circulation (reflux) just below the skin, simple vein surgery and compression treatment may prevent ulcers from coming back.

Treatment

If you have developed a venous skin ulcer, your treatment may include:

  • Compression bandages and elevation. If an ulcer has formed, a dressing may be placed over the wound before the compression is put on. The dressing may contain medicine to help heal the ulcer.
  • Debridement, or removal, of any dead tissue on the wound. Debridement is often used to help a skin ulcer heal properly.
  • A balanced diet, dietary supplements, and exercise. For more information, see the Home Treatment section of this topic.

If your skin ulcer does not heal within 2 to 3 months of standard compression treatment, your doctor may recommend additional treatment. A number of options are available, including:

  • Pentoxifylline, an oral medicine that may speed healing when used with compression.
  • Antibiotics , used only when an infection is present. They do not improve ulcer healing.
  • Intermittent pneumatic compression (IPC) pump. These devices alternately inflate and deflate knee-high boots, which results in decreased pooling of blood in the legs. IPC pumps can be used at home for ulcers that have not healed with conventional compression therapy.
  • Skin grafting, an effective treatment for deep or long-standing and difficult-to-heal skin ulcers.
  • Vein surgery, which does not improve healing but may help prevent recurring ulcers. Surgery may be useful for specific vein problems or hard-to-heal skin ulcers. For more information on vein surgery, see the topic Varicose Veins.

Home Treatment

Venous skin ulcers can take months to heal and often recur. You can reduce your healing time and your risk of having an ulcer recur by taking the following important measures:

  • Carefully follow your doctor's instructions for wound care. And ensure that your compression bandages are changed regularly. Bandages are typically changed weekly.
  • Avoid smoking and excessive alcohol use. These impair skin ulcer healing and prevention.
  • For both treatment and prevention, elevate your legs above the level of your heart whenever possible. Prop the foot end of your bed up 6 in. (15 cm) to 8 in. (20 cm) on blocks. During waking hours, try to elevate your legs higher than your heart for 30 minutes, 3 to 4 times a day.
  • Maintain a balanced, nutritious diet.
  • Exercise regularly. Walking is an excellent activity for improving lower leg circulation.
  • Avoid prolonged standing or sitting, both of which slow healing.
  • Ask your doctor whether aspirin may help your ulcer heal more quickly.

Some people try complementary medicine. One example is herbal remedies, such as horse chestnut (aescin). Some people try supplements, such as flavonoids. Be sure to tell your doctor about any herbs or vitamin supplements you are taking.

After your wound has healed, wear your compression stockings regularly, removing them only for bathing and sleeping. Compression is the key to preventing venous skin ulcers. For more information, see:

Click here to view an Actionset. Venous skin ulcers: Using compression stockings.

Other Places To Get Help

Organization

American Academy of Dermatology
P.O. Box 4014
Schaumburg, IL  60618-4014
Phone: 1-866-503-SKIN (1-866-503-7546) toll-free
(847) 240-1280
Fax: (847) 240-1859
Web Address: www.aad.org
 

The American Academy of Dermatology provides information about the care of skin, hair, and nails. You can find a dermatologist in your area by calling 1-888-462-DERM (1-888-462-3376).


References

Other Works Consulted

  • Burton CS, et al. (2008). Cutaneous changes in venous and lymphatic insufficiency. In K Wolff et al., eds., Fitzpatrick's Dermatology in General Medicine, 7th ed., pp. 1679–1686. New York: McGraw-Hill.
  • Katz DL, Friedman RSC (2008). Diet and wound healing. In Nutrition in Clinical Practice, 2nd ed., pp. 271–274. Philadelphia: Lippincott Williams and Wilkins.
  • Raju S, Neglen P (2009). Chronic venous insufficiency and varicose veins. New England Journal of Medicine, 360(22): 2319–2327.

Credits

Author Robin Parks, MS
Editor Kathleen M. Ariss, MS
Associate Editor Pat Truman, MATC
Primary Medical Reviewer Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer Margaret Doucette, DO - Physical Medicine and Rehabilitation, Wound Care, Hyperbaric Medicine
Last Updated September 3, 2009

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