LEG ULCERS

What are leg ulcers?

A leg ulcer is a break in the skin of the lower leg or foot that fails to heal within four to six weeks. They are a common but often undertreated condition, affecting around 1% of the adult population in the UK and up to 3% of people over 65. Leg ulcers cause significant pain, limit mobility, and can have a major impact on quality of life.

The vast majority of leg ulcers have a vascular cause — either venous (related to poor venous drainage) or arterial (related to poor arterial blood supply). Identifying the underlying cause is essential to selecting the right treatment, as the management of venous and arterial ulcers differs fundamentally.

Types of leg ulcer

Venous leg ulcers (most common)

Venous ulcers develop when the veins in the leg fail to return blood efficiently to the heart, causing a build-up of pressure in the lower leg. This raised venous pressure damages the skin and underlying tissues, eventually leading to ulceration. They typically occur above the ankle on the inner aspect of the leg and are associated with:
•    Varicose veins or a history of deep vein thrombosis (DVT)
•    Swollen ankles and legs
•    Skin changes including discolouration, hardening (lipodermatosclerosis), and eczema
•    A shallow, irregular wound with a moist base

Arterial leg ulcers (around 10–15%)
Arterial ulcers develop when insufficient blood reaches the tissues of the lower leg and foot due to narrowed or blocked arteries (peripheral arterial disease). They tend to occur on the foot, toes, or shin and are characterised by:
•    A deep, well-defined, often painful wound
•    Pale or necrotic wound base
•    Cold, pale, or blue-tinged skin on the foot
•    Rest pain or a history of claudication
 

Mixed aetiology ulcers
A significant proportion of leg ulcers have both venous and arterial components. Accurate assessment of the arterial supply — using ankle-brachial pressure index (ABPI) measurement and duplex ultrasound — is essential before any compression treatment is applied, as compression is contraindicated in the presence of significant arterial disease.
 

Diabetic foot ulcers
People with diabetes are at particularly high risk of foot ulceration due to a combination of peripheral neuropathy (nerve damage reducing pain sensation) and peripheral arterial disease. Diabetic foot ulcers require specialist multidisciplinary assessment and are a leading cause of lower limb amputation in the UK. Professor Zayed has a specialist interest in diabetic vascular disease and limb salvage.

How are leg ulcers assessed?

A thorough vascular assessment is the foundation of effective ulcer management. Professor Zayed uses a combination of:

•    Clinical examination — wound characteristics, skin changes, limb temperature and pulses
•    Ankle-brachial pressure index (ABPI) — to assess arterial supply and guide compression use when appropriate
•    Duplex ultrasound — to examine both the venous and arterial systems of the leg
•    CT or MR angiography — where arterial intervention is being considered

Treatment options

Venous ulcers — compression and venous intervention
High-compression bandaging or hosiery is the cornerstone of venous ulcer treatment, reducing venous pressure and promoting healing. However, compression alone does not address the underlying venous disease. Professor Zayed assesses each patient for suitability for venous intervention — including Radiofrequency Ablation (RFA) or foam sclerotherapy — to treat the underlying reflux and significantly reduce the risk of ulcer recurrence.

Arterial ulcers — restoring blood flow
The priority in arterial ulceration is restoring adequate blood supply to the affected limb. Depending on the pattern and severity of arterial disease, Professor Zayed offers endovascular techniques (angioplasty and stenting) or surgical bypass to restore the blood supply to the limb and create favourable conditions for wound healing.

Wound care and debridement
Alongside vascular intervention, appropriate wound management is essential. This includes debridement of non-viable tissue, infection control, and selection of appropriate dressings to optimise the wound healing environment.