Clinical features

The natural history of the disease is of a continuous cycle of healing and breakdown over decades and chronic venous leg ulcers are associated with considerable morbidity and impaired quality of life (1).

Venous ulcers are usually found within the "gaiter" region of the lower leg, characteristically around the malleoli (2). If ulcers are present above the mid calf or on the foot, it is most likely to be due to some other aetiology.

Signs of venous ulcers usually vary according to the severity of the condition.

• skin changes present in venous hypertension (sometimes may precede venous ulcers)
  • varicosities of the lower leg
  • oedema - often worse towards the end of the day
  • venous dermatitis usually with hyperpigmentation as a result of deposition of haemosiderosis or haemoglobin in the skin
  • lipodermatosclerosis
    • seen in long term venous insufficiency
    • associated with thickening and fibrosis of normal adipose tissue under the skin
    • skin also becomes atrophic, loses sweat glands and hair follicles, and becomes variably pigmented (ranging from hypopigmented to hyperpigmented)
    • leg may resemble an “inverted champagne bottle.” in patients with severe lipodermatosclerosis
  • venous eczema (erythema, scaling, weeping, and itching (1,2,3)

Ulcers are usually irregular and shallow.

• the wound edge is usually 'sloping'
• ulcer bed often contains fibrous or necrotic tissue mixed with granulation tissue (1).

Venous ulcers may be painful

Arterial disease should be excluded by:

• palpation of good volume dorsalis pedis and posterior tibial pulses, or
• the presence of an ankle-brachial pressure ratio, as determined by Doppler ultrasound, in excess of 0.8

Reference:

1. Scottish Intercollegiate Guidelines Network (SIGN) 2010. Management of chronic venous leg ulcers

2. Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ. 2006;332(7537):347-50.

3. Collins L, Seraj S. Diagnosis and treatment of venous ulcers. Am Fam Physician. 2010;81(8):989-96.