South Tyneside NHS Foundation Trust

Venous Leg Ulcers

Providing a range of NHS services in Gateshead, South Tyneside and Sunderland.

What Causes venous leg ulcers? A venous leg ulcer can develop after a minor injury if there is a problem with the circulation of blood in the veins of your leg. If this happens, the pressure inside the veins increases and this can gradually damage the tiny blood vessels in your skin and make it fragile. If you then knock or scratch your skin, it can easily break and form an ulcer. Unless you have treatment to improve the circulation in your legs, the ulcer can take a long time to heal. A venous leg ulcer is the most common type of leg ulcer. Who is most at risk? A number of things can increase your risk of developing a venous leg ulcer, including: • if you are very overweight, this can cause high pressure in the veins in your legs • not being able to move for a long period of time  can weaken your calf muscles, which can affect circulation in the veins in your legs • if you have already had deep vein thrombosis (DVT) – blood clots that develop in the leg, as this can permanently damage the veins in your legs. • if you have varicose veins which are swollen and enlarged veins caused by valves that don’t work properly • if you have previously injured your leg, such as a broken or fractured bone, which might have caused DVT • previous surgery to your leg, such as a hip replacement or knee replacement, which can prevent you from moving about • as people get older they generally find it harder to move about

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How do I know if I’ve got a venous leg ulcer? Venous leg ulcers are open, often painful, sores in the skin that take more than four weeks to heal. They most often develop between your knee and ankle. If you have a venous leg ulcer, you may also have: • swollen ankles (oedema) • darkening of your skin around the ulcer • hardened skin around the ulcer, which may make your leg feel hard and resemble the shape of an upside-down champagne bottle • a heavy feeling in your legs • aching or swelling in your legs • red, flaky, scaly and itchy skin on your legs (varicose eczema) swollen and enlarged veins on your legs also known as varicose veins • an unpleasant discharge from the ulcer

Physical examination and medical history Your doctor or nurse will examine both your legs, when you are standing up and lying down. This is because varicose veins can be seen more clearly when you are standing up, and it will be easier to examine the ulcer when you are lying down. They will ask whether you have any additional symptoms, such as swelling in your ankles and discoloured or hardened skin. They will also feel your pulse at your ankles to make sure the arteries in your leg are working properly. Your doctor or nurse may try to determine the cause of the ulcer by asking about any other health conditions you may have, such as diabetes or DVT and any previous injuries, ulcers or surgery you may have had on your affected leg. What is a Doppler ultrasound test? The doctor or nurse will want to rule out other conditions as possible causes of your symptoms, so they will carry out a test known as a Doppler ultrasound test.

Do I need to seek medical advice? You should contact your doctor or nurse if you think you have developed a venous leg ulcer. Venous leg ulcers are unlikely to get better on their own and you will probably need specialist treatment.

The test involves measuring the blood pressure in your arteries in your ankles and comparing it to the blood pressure in your upper arms. These measurements are taken with an ultrasound probe, which uses sound waves to determine the flow of blood in your arteries.

You should also contact your doctor or nurse or tissue viability team if you have been diagnosed with a venous leg ulcer and think that it might be infected.

The blood pressure in your arteries should be about the same in your arms as in your legs. If the blood pressure in your ankles is lower than that in your arms you may have peripheral arterial disease this is treated differently from venous leg ulcers.

How will the doctor / nurse tell I have got a venous leg ulcer? The doctor or nurse will be able to diagnose a venous leg ulcer from listening to you telling them your symptoms and examining your affected leg. Sometimes additional tests may be required.

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One of the main treatments used for venous ulcers is wearing compression bandages to improve the circulation in your legs, but this can make things worse if you have peripheral arterial disease.

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What is the treatment for a venous leg ulcer? With the right treatment, most venous leg ulcers will heal within three or four months.

It’s important to wear your compression bandage or garment exactly as instructed by your nurse and if you have any problems, please contact your nurse.

Cleaning and dressing your ulcer The first step is to remove any debris or dead tissue from your ulcer and apply simple, non-sticky dressing. This will provide the best conditions for the ulcer to heal and will usually need to be changed once a week.

However, if you get severe pain at the front of your ankle or on the top of your foot, or if your toes become blue and swollen, please take off the compression bandage or garment immediately. Keep your leg highly elevated (higher than your heart) and contact your nurse as soon as possible.

Using compression bandages and garments To help improve the circulation in your legs, your nurse will need to apply a supportive compression bandage or garment over your affected leg. These bandages and garments are designed to squeeze your legs and encourage blood to flow upwards towards your heart.

What is the treatment for your other symptoms?

There are many different types of bandage and garments used to treat venous leg ulcers and they can be made up of one, two, three or four different layers. Your nurse has been specially trained in treating venous leg ulcers and will help you decide which type of compression treatment you need. The decision to apply compression is a skilled procedure and should only be done by a healthcare professional trained in leg ulcer management.

You can also help by keeping your affected leg elevated whenever possible, ideally with your toes at the same level as your eyes. You may find it helpful to put something firm under the end of your mattress, to help keep your legs raised while you sleep.

The nurse will apply the bandage or garment over the dressing on your venous leg ulcer. The bandage will be changed once a week when the dressing is changed. However, if the nurse has fitted you with a garment, they will show you how to remove it and put it on again so you can have a bath or a shower.

Swelling in your legs and ankles People who have venous leg ulcers often have swollen feet and ankles too, which is caused by fluid build-up. This should be reduced and then controlled by your compression.

You should also keep as active as possible and try to continue with your normal activities. Regular exercise, such as a daily walk, will help reduce swelling in your leg. However, always raise your legs higher than your heart when you sit down and try not to stand still for longer than an hour at a time.

When compression bandages are first applied to your venous leg ulcer ulcer, it can become more painful. You should have some painkillers prescribed by your doctor and the pain will reduce once the ulcer starts to heal, which may take between 10 and 12 days.

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Itchy skin Some people with venous leg ulcers develop a condition called varicose eczema, which can be treated with a moisturiser (emollient) and occasionally a mild corticosteroid cream or ointment. Your doctor or nurse will advise you about which is best for you and arrange a prescription if necessary. If your itching is severe, your doctor or nurse may refer you to a dermatologist (skin specialist) for treatment. Itchy skin may also be caused by an allergic reaction to the dressings or creams applied. If this happens, your nurse will arrange for you to be tested for allergies and change the dressings or creams. It’s important to avoid scratching your legs if they feel itchy, because this could damage your skin and cause more ulcers. How can you look after yourself during treatment? To help your ulcer heal more quickly: • • • • •

Try to keep active by walking regularly. Sitting and standing still without elevating your legs can make your venous leg ulcers and swelling worse Whenever you are sitting or lying down, try to keep your affected leg elevated higher than your heart Regularly exercise your legs by moving your feet up and down, and rotating them at the ankles. This will help improve circulation. Ask your nurse to show you the exercises Stop smoking, eat a healthy diet and try to reduce your alcohol consumption. This can help your ulcer heal faster. Be careful not to injure your affected leg, and wear comfortable, well-fitting footwear.

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What are the signs that my venous leg ulcer is infected? A venous leg ulcer can easily be infected by bacteria. Your venous leg ulcer might be infected if you experience some or all of the following: • • • •

you have a high temperature and feel feverish worsening pain a unpleasant discharge coming from the ulcer redness and swelling of your skin around the ulcer

What is the treatment for an infected venous leg ulcer? If your ulcer becomes infected, it should be cleaned and dressed as usual, although you may need to stop wearing your compression bandage or garment if it is too painful until the infection has cleared. You should also keep your leg elevated higher than your heart whenever possible. If the doctor or nurse has investigated and said you have an infection they will usually prescribe you a seven-day course of antibiotics. This will be to treat the infection and will have no effect on healing your venous leg ulcer. Your doctor or nurse will only prescribe antibiotics for short courses of treatment. What support can we give you while your venous leg ulcer is healing? You will be given appointments to see your nurse once a week to have your dressings and compression bandages and garments changed. They will also check on your ulcer to see how well it is healing. Once your ulcer is healing well, you will probably need to see your nurse less often.

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Preventing a venous leg ulcer  You can help reduce your risk of developing a venous leg ulcer in several ways, such as wearing compression garments, losing weight and taking care of your skin. People most at risk of developing a venous leg ulcer are those who have previously had a leg ulcer. Studies have shown there is a significant chance another could develop a few months or years after a previous ulcer heals. Compression stockings If you have previously had a venous leg ulcer, or your doctor / nurse thinks you may be at risk of developing one (for example, if they notice hardening of the skin on your legs, which often occurs after an ulcer), treatment with compression garments will be recommended. These garments are specially designed to steadily squeeze your legs, which improves your circulation. They are usually most supportive at the ankle and get gradually looser as they go further up your leg – this encourages blood to flow upwards, towards your heart. To be most effective, these garments need to be worn at all times when you are out of bed. Compression garments are available in a variety of different sizes, colours, styles and pressures. Your practice or district nurse can help you find a garment that fits correctly and that you can manage yourself. Don’t worry if you think you will struggle with this as there are lots of accessories to help get the garments on and off.

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Losing weight If you are overweight, losing weight can help prevent venous leg ulcers. This is because excess weight leads to high pressure in the veins in your legs, which can damage your skin. Venous ulcers are much more common among people who are overweight than in people of normal weight. To help you lose weight, at least 30 minutes of exercise 5 times a week is recommended. You should also try to have a healthy, balanced diet. If you are unable to do this amount of exercise a week, you should aim for 45 minutes of moderate intensity exercise at least three times a week. Walking is a great form of moderate intensity exercise, and you should avoid sitting or standing for long periods. Elevating your legs higher than the level of your heart whenever possible can also help. Treating underlying problems In some cases, you may be able to receive treatment for a condition that can increase your chances of developing a venous leg ulcer, such as varicose veins. Varicose veins can often be treated using a procedure where a catheter (a thin, flexible tube) is inserted into the affected veins, and high-frequency radio waves or lasers are used to seal them. This does not involve staying in hospital, it is usually done as an out patient and you will be able to go home after the procedure. Alternatively, you may need surgery to repair the damage to your leg veins, or to remove the affected veins altogether. If you would like to be referred to see if you are suitable for treatment of your varicose veins discuss this with your doctor or nurse.

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For further details / information please contact: Tissue Viability Service Monday to Friday 8.30am to 5.00pm on 0191 283 1432 South Tyneside District Hospital Harton Lane South Shields NE34 0PL Tel. 0191 4041000 www.stft.nhs.uk

We are committed to raising the standard of written information for patients, their carers, people who use the NHS and the general public. This information can be made available in another format or language on request. For further copies of this leaflet please contact on telephone numbers above. Production date: Dec 2015

Author: Tissue Viability

Code: 1215/417

Review date: Dec 2015