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Leg ulcer, venous - Treating a venous leg ulcer

NHS Choices Medical Reference

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A venous ulcer can be healed by either applying strong sustained compression with a bandage or a stocking, and by treating the underlying cause of the ulcer. When appropriate, both treatments can be used at the same time.

Following the advice below may help your venous leg ulcer heal more quickly:

  • Try to keep active by walking regularly. Immobility can make venous leg ulcers and the associated symptoms, such as oedema (swollen, fluid-filled areas), worse.
  • Whenever you are sitting or lying down, try to keep your affected leg elevated.
  • Be careful not to injure your affected leg, and wear only comfortable well-fitting footwear.
  • If you are prescribed an emollient by your nurse for venous eczema, use it as often as possible. The motion of rubbing in the emollient boosts your circulation and there is no limit to how often you can use it.
  • Wear your compression bandage exactly as instructed by your nurse. If you have any problems with it, do not remove it yourself.

The specific treatment options are described in more detail below.

Compression treatment

Application of a firm compression bandage or a graduated elastic medical compression stocking to a leg with a venous ulcer is one of the most effective methods of treatment. This will lead to about 70% of ulcers healing within six months.

Before starting compression treatment, it is essential that a Doppler test is used to measure the ankle and arm blood pressures to make sure the arteries are working normally in the leg. Gangrene may result from the use of compression treatment in patients with severe peripheral arterial disease in the leg.

Graduated elastic medical compression stockings can be used by patients with reasonable strength in their hands, since they can be a little difficult to put on. Modern systems are available that contain two stockings; both are worn on the ulcerated leg during the day and one is removed at night. These are easier to use than one heavy stocking.

Ulcer dressings (see below) can be applied after removing both stockings. Many patients find they can manage this themselves.

There are many different types of bandage used to treat venous leg ulcers. Some use just one type of bandage, while others are made up of several layers. The application of a compression bandage is a skilled procedure and should be done by a healthcare professional trained in leg ulcer management.

Bandaging of the leg is usually done after a leg ulcer dressing change. The bandage and ulcer dressing can then remain in place for up to a week, depending on how often ulcer dressing changes are required.

Ulcer dressings

The aim of applying a dressing to an ulcer is to provide conditions for the ulcer to allow healing. It has been found that the actual dressing type that is used does not influence how quickly the ulcer heals.

The first stage is to clean the ulcer. This can be done by gentle washing in warm tap water. Sometimes saline (salt water) is used instead. The aim of this is to remove debris and dead tissue that accumulates on the surface of the ulcer between dressing changes. Removal of this helps ulcer healing.

If there is a large amount of dead tissue, the nurse may need to remove it using a technique called debridement. Specially designed dressings may be used to pull away dead tissue or chemicals to dissolve the dead tissue. It is performed under local anaesthetic (where the area is numbed), so it does not hurt.

A simple, non-sticky dressing will be used to dress your ulcer. This will aid healing, improve comfort and control any pus. Many patients find they can manage cleaning and dressing of their own ulcer under the supervision of a district nurse.

Treating an infected leg ulcer

Sometimes an ulcer will produce a large amount of pus and become more painful, and some red inflammation may develop around the ulcer. These symptoms may be a sign of infection.

Cleaning of the ulcer should continue as usual and a dressing applied. Where possible, application of compression treatment should  also be used. However, sometimes the leg may be too painful to allow this. Temporarily, compression can be reduced or avoided until the leg is more comfortable.
You will be prescribed a seven-day course of antibiotic tablets to treat your infection. In most cases you will be given penicillin. If you are allergic to penicillin, an alternative antibiotic such as erythromycin can be used.

Side effects of antibiotics are usually mild and short-lived. They include:

You will need to return to your nurse daily, or every other day, to ensure your antibiotics are working, until the infection has cleared. If there is no improvement, your nurse may change your antibiotic, which you may need to take for up to two weeks.

In rare cases where the infection gets worse and you begin to feel very unwell, you may need intravenous antibiotic treatment (antibiotics injected into the vein) in hospital.

The aim of antibiotic treatment is to treat the infection - however, antibiotics have no beneficial effect on ulcer healing and should only be used in short courses to treat ulcers that have become infected.

Follow-up treatment

You should return to your nurse once a week to have your dressings and compression bandages changed. They will also monitor the ulcer to see how well it is healing. Once your ulcer is healing well, you may only need to see your nurse once a month.

Treating associated symptoms

Pain

Venous leg ulcers can often be painful. Mild to moderate leg pain can be treated using paracetamol. However, if your pain is more severe and does not respond to paracetamol, your healthcare professional may prescribe a combination of paracetamol and ibuprofen.

If after treatment your leg pain has continued to worsen, you should inform your nurse because you may have developed a complication such as an infection.

Leg swelling (oedema)

Venous leg ulcers are often accompanied by oedema (fluid-filled swelling of your ankles and feet). This is effectively controlled with the use of compression bandages or graduated elastic medical compression stockings.

Keeping your affected leg elevated will also usually help ease any swelling. Try keeping your leg raised above hip level for 30 minutes, three or four times a day. Putting pillows or cushions under your feet when you are asleep may also help.

However, it is important that you also keep as active as possible and aim to continue with your normal activities. Regular exercise, such as a daily walk, will help reduce swelling in the legs but do not stand still for long periods of time.

Itchy skin

Itchy and irritated skin associated with a venous ulcer is known as varicose eczema, and is caused by the fluids leaking out of veins into surrounding tissue.

If you have severe or worsening varicose eczema, your nurse will first need to rule out cellulitis (a bacterial infection of the deep layer of skin). If you have cellulitis, you will be given antibiotics.

To treat varicose eczema, your nurse may suggest using an emollient (moisturiser) on the affected area, as well as a mild corticosteroid cream or ointment. These will ease itching and encourage the skin to heal.

If your eczema does not improve or continues to get worse despite treatment, you may have an allergic reaction known as contact dermatitis. You may be allergic to your dressing, emollient or corticosteroid.

If contact dermatitis is suspected, you may need to be referred to a dermatologist (skin specialist) for a patch test. This involves taping a small amount of the suspected allergen to your skin for 48 hours to see how it reacts.

Contact dermatitis can occur at any stage of your treatment for a venous ulcer, and not just at the start.

Specialist treatment

If your venous leg ulcer does not heal, even after two to three months of treatment, you will need to be referred for specialist treatment to find out why. The specialist will be able to arrange further investigations such as colour duplex ultrasound imaging or biopsy of the ulcer to determine what is preventing your ulcer from healing.

Varicose veins are a common cause of leg ulcers and modern treatments can be used alongside compression treatments to improve and maintain ulcer healing.

In very rare cases, a venous leg ulcer may not heal, even after specialist treatment. If this is the case, your healthcare professional will aim to make your ulcer as easy to live with as possible by controlling any associated symptoms and improving your mobility. You may be offered long-term psychological support if it is needed.

After the leg ulcer has healed

Once a leg has suffered a venous ulcer, there is a one in four chance of further ulceration developing within the next two years. The most effective method of preventing this is to wear a graduated elastic medical compression stocking at all times when you are out of bed. Your nurse will help you find a stocking that fits correctly and which you can manage yourself.

Various accessories are available to help you put these on and take them off.

Treating underlying conditions

Venous ulcers are caused by the failure of valves in the veins of the leg. Commonly, this arises in the surface veins and causes varicose veins.

Read more information about how varicose veins are treated.

Sometimes, it is the deep veins of the leg that are the problem. These may be damaged following a deep vein thrombosis (DVT). Unfortunately, the valves in deep veins are not easily repaired and compression treatment (see above) is the best method in most cases. There are no drugs that can be taken or topical ointments that can be applied to heal the ulcer.

Treatment for venous leg ulcers should always be carried out by a healthcare professional trained in leg ulcer management. In most cases, this will be a trained practice or district nurse.

Read more information about preventing a venous leg ulcer.

Medical Review: April 14, 2012
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