Causes
Venous ulcers are primarily caused by chronic venous insufficiency (CVI), a condition where the valves in the leg veins become damaged or weakened. This causes blood to pool in the lower legs, leading to high pressure in the veins (venous hypertension). Over time, this sustained high pressure damages capillaries, allowing fluid and blood cells to leak into the surrounding tissues, leading to inflammation, swelling, and eventually skin breakdown and ulcer formation. Key factors contributing to venous ulcer disease include:- Chronic Venous Insufficiency (CVI): The most direct cause, resulting from damaged or incompetent venous valves.
- Deep Vein Thrombosis (DVT): A history of DVT (blood clots in deep veins) can damage venous valves, leading to post-thrombotic syndrome and CVI.
- Varicose Veins: Enlarged, twisted veins that indicate underlying venous insufficiency.
- Obesity: Excess weight puts increased pressure on leg veins.
- Lack of Physical Activity: Muscle pump in the legs (which helps push blood) is less active.
- Prolonged Standing or Sitting: Can worsen blood pooling in the legs.
- Age: Risk increases with age due to general wear and tear on veins.
- Trauma or Injury to the Leg: Can predispose the area to ulcer formation if CVI is present.
- Heart Failure: Can contribute to fluid retention and increased venous pressure.
- Pregnancy: Hormonal changes and increased pressure on pelvic veins can contribute to venous insufficiency.
- Genetics: A family history of venous disease.
Symptoms
Venous ulcer disease often develops in stages, with symptoms progressing before an ulcer forms:- Early Symptoms (before ulcer forms):
- Swelling (edema): In the ankles and legs, often worse at the end of the day.
- Skin discoloration: Reddish-brown or rusty appearance (hemosiderin staining) on the lower legs due to leakage of red blood cells.
- Itching and dryness: Skin may become flaky and itchy (stasis dermatitis).
- Heavy or aching legs: Especially after standing or sitting for long periods.
- Varicose veins: Visible, bulging veins.
- Ulcer Symptoms:
- Open sore: Typically develops on the inner ankle or calf area, but can occur anywhere on the lower leg.
- Irregular shape: Ulcers often have irregular borders.
- Shallow depth: Usually not very deep.
- Exudate: May produce a clear, yellowish, or sometimes purulent discharge.
- Pain: Can range from mild to severe, often worse when the leg is dependent (hanging down) and relieved when elevated.
- Surrounding skin: May be discolored, swollen, shiny, or hardened.
- Infection: Signs include increased pain, redness, warmth, pus, and fever.
Diagnosis
Diagnosing venous ulcer disease involves a physical examination, medical history, and tests to assess circulation.- Medical History and Physical Exam: The doctor will ask about your symptoms, medical history (especially DVT, varicose veins, heart failure), and examine your legs for swelling, skin changes, and the ulcer itself. They will also check pulses in your feet.
- Ankle-Brachial Index (ABI): A quick, non-invasive test that compares blood pressure in your ankle to blood pressure in your arm. This helps rule out peripheral arterial disease (PAD), which can also cause leg ulcers and requires different treatment.
- Duplex Ultrasound (Venous Ultrasound): This is the primary diagnostic tool. It uses sound waves to visualize blood flow in the leg veins, identify incompetent valves, and detect any residual blood clots.
- Blood Tests: May be done to rule out diabetes or other conditions that could impair healing.
- Wound Culture: If infection is suspected, a sample from the ulcer may be sent for culture to identify bacteria.
Treatment
Treatment for venous ulcers focuses on healing the ulcer, managing swelling, preventing infection, and addressing the underlying venous insufficiency to prevent recurrence. Compression Therapy (Cornerstone of Treatment): Compression bandages or stockings: Applied from the toes to just below the knee, these are essential to reduce swelling, improve blood flow, and counteract venous hypertension. They must be worn daily.- Wound Care:
- Cleaning: The ulcer is cleaned regularly to remove dead tissue and exudate.
- Dressings: Specialized dressings (e.g., hydrocolloids, foams, alginates) are used to maintain a moist wound environment, absorb exudate, and promote healing.
- Debridement: Removal of dead or infected tissue from the ulcer, which may be done surgically or with specialized dressings.
- Elevation of the Legs: Elevating the legs above heart level whenever possible (especially at night) helps reduce swelling.
- Medications:
- Antibiotics: Prescribed if the ulcer becomes infected.
- Pentoxifylline: May be prescribed to improve blood flow and aid healing.
- Aspirin: Low-dose aspirin may be considered in some cases to improve microcirculation.
- Addressing Underlying Venous Insufficiency:
- Exercise: Walking and calf muscle exercises help improve the calf muscle pump.
- Weight Management: Losing excess weight can reduce pressure on leg veins.
- Endovenous Ablation: Minimally invasive procedures (e.g., laser or radiofrequency ablation) to close off incompetent veins.
- Sclerotherapy: Involves injecting a solution into veins to close them.
- Surgery: Rarely needed for ulcers, but may be used to repair damaged veins or remove large varicose veins.
- Prevention of Recurrence:
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- Lifelong use of compression stockings.
- Regular exercise and leg elevation.
- Management of risk factors (e.g., obesity, heart failure).
Getting a Venous Ulcer to Heal, and Keeping It Healed
Most venous ulcers close within a few months when compression is applied properly and worn every day, and most that fail were never compressed adequately. The details below separate a wound that heals from one that lingers for years.
Compression is the treatment, and it must be strong enough
Healing requires firm compression, a multilayer bandage applied by a wound clinic or a prescription-strength stocking, not pharmacy support hose. The bandage is changed weekly with the dressing and stays on around the clock. An ankle-brachial index is checked first, because tight compression on a leg with peripheral arterial disease causes harm and a low value changes the plan. Our chronic venous insufficiency article explains the disease behind the ulcer.
Fixing the vein prevents the next ulcer
Ultrasound usually finds a refluxing superficial vein, and closing it with heat or foam early rather than after healing speeds closure and roughly halves recurrence. Once closed, lifelong daytime compression stockings remain necessary, replaced every few months as they lose their stretch. The varicose veins and venous insufficiency page covers the procedures, and a prior deep vein thrombosis is checked for because the plan changes when the deep veins are scarred.
Infection, and what is not infection
Ulcers are always colonized with bacteria, and culturing a wound that is healing normally leads to needless antibiotics. Treatment such as cephalexin or doxycycline is reserved for spreading redness, warmth, new pain, fever, or a foul odor, the signs of cellulitis. Itchy red skin around the ulcer is more often stasis dermatitis or an allergy to a dressing or ointment, treated with a steroid cream. An open leg wound stays out of the Gulf, the bay, and canals; our Vibrio safety article explains why.
What slows healing quietly
Uncontrolled diabetes, smoking, obesity, low protein intake, and swelling from heart failure or a calcium-channel blocker each stall an otherwise well-treated wound. Walking daily works the calf pump; standing still or sitting with legs down does the opposite. An ulcer that has not shrunk after several weeks of good care, or looks unusual, is biopsied, because skin cancers occasionally hide in old wounds.
Recurrence and the long term
Without stockings, most healed ulcers reopen within a few years; with them, most stay closed. Daily moisturizing, avoiding leg trauma, treating coexisting lymphedema, and seeing a clinician at the first sign of skin breakdown keep small problems small. Our cardiovascular team coordinates vascular referral. MedlinePlus and the Society for Vascular Surgery publish patient guidance.
If a sore above your ankle has been open for more than two weeks, or a healed one is breaking down again, schedule a visit.