Skip to main content
Postgraduate Medical Journal logoLink to Postgraduate Medical Journal
. 2000 Nov;76(901):674–682. doi: 10.1136/pmj.76.901.674

Management of leg ulcers

P Sarkar 1, S Ballantyne 1
PMCID: PMC1741806  PMID: 11060140

Abstract

Leg ulcer is a leading cause of morbidity among older subjects, especially women in the Western world. About 400 years BC, Hippocrates wrote, "In case of an ulcer, it is not expedient to stand, especially if the ulcer be situated on the leg". Hippocrates himself had a leg ulcer. The best treatment of any leg ulcer depends upon the accurate diagnosis and the underlying aetiology. The majority of leg ulcers are due to venous disease and/or arterial disease, but the treatment of the underlying cause is far more important than the choice of dressing. The aetiology, pathogenesis, treatment, and the future trends in the management of the leg ulcers are discussed in this review.


Full Text

The Full Text of this article is available as a PDF (156.0 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Alvarez O. M., Fahey C. B., Auletta M. J., Fernández-Obregón A. A novel treatment for venous leg ulcers. J Foot Ankle Surg. 1998 Jul-Aug;37(4):319–324. doi: 10.1016/s1067-2516(98)80069-0. [DOI] [PubMed] [Google Scholar]
  2. Angle B., Burton B. K. Familial leg ulcers. Lancet. 1998 Apr 4;351(9108):1031–1032. doi: 10.1016/S0140-6736(05)78998-4. [DOI] [PubMed] [Google Scholar]
  3. Barranco S. D., Spadaro J. A., Berger T. J., Becker R. O. In vitro effect of weak direct current on Staphylococcus aureus. Clin Orthop Relat Res. 1974 May;(100):250–255. [PubMed] [Google Scholar]
  4. Belcaro G., Rulo A., Candiani C. Evaluation of the microcirculatory effects of Venoruton in patients with chronic venous hypertension by laserdoppler flowmetry, transcutaneous PO2 and PCO2 measurements, leg volumetry and ambulatory venous pressure measurements. Vasa. 1989;18(2):146–151. [PubMed] [Google Scholar]
  5. Biland L., Widmer L. K. Varicose veins (VV) and chronic venous insufficiency (CVI). Medical and socio-economic aspects, Basle study. Acta Chir Scand Suppl. 1988;544:9–11. [PubMed] [Google Scholar]
  6. Blackburn J. H., 2nd, Boemi L., Hall W. W., Jeffords K., Hauck R. M., Banducci D. R., Graham W. P., 3rd Negative-pressure dressings as a bolster for skin grafts. Ann Plast Surg. 1998 May;40(5):453–457. doi: 10.1097/00000637-199805000-00001. [DOI] [PubMed] [Google Scholar]
  7. Browse N. L., Burnand K. G. The cause of venous ulceration. Lancet. 1982 Jul 31;2(8292):243–245. doi: 10.1016/s0140-6736(82)90325-7. [DOI] [PubMed] [Google Scholar]
  8. Browse N. L., Gray L., Jarrett P. E., Morland M. Blood and vein-wall fibrinolytic activity in health and vascular disease. Br Med J. 1977 Feb 19;1(6059):478–481. doi: 10.1136/bmj.1.6059.478. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Browse N. L., Jarrett P. E., Morland M., Burnand K. Treatment of liposclerosis of the leg by fibrinolytic enhancement: a preliminary report. Br Med J. 1977 Aug 13;2(6084):434–435. doi: 10.1136/bmj.2.6084.434. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Burnand K. G., Clemenson G., Whimster I., Gaunt J., Browse N. L. The effect of sustained venous hypertension on the skin capillaries of the canine hind limb. Br J Surg. 1982 Jan;69(1):41–44. doi: 10.1002/bjs.1800690114. [DOI] [PubMed] [Google Scholar]
  11. Burnand K. G., Whimster I., Clemenson G., Thomas M. L., Browse N. L. The relationship between the number of capillaries in the skin of the venous ulcer-bearing area of the lower leg and the fall in foot vein pressure during exercise. Br J Surg. 1981 May;68(5):297–300. doi: 10.1002/bjs.1800680502. [DOI] [PubMed] [Google Scholar]
  12. Burnand K. G., Whimster I., Naidoo A., Browse N. L. Pericapillary fibrin in the ulcer-bearing skin of the leg: the cause of lipodermatosclerosis and venous ulceration. Br Med J (Clin Res Ed) 1982 Oct 16;285(6348):1071–1072. doi: 10.1136/bmj.285.6348.1071. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Burnand K., Clemenson G., Morland M., Jarrett P. E., Browse N. L. Venous lipodermatosclerosis: treatment by fibrinolytic enhancement and elastic compression. Br Med J. 1980 Jan 5;280(6206):7–11. doi: 10.1136/bmj.280.6206.7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Callam M. J., Harper D. R., Dale J. J., Ruckley C. V. Chronic ulcer of the leg: clinical history. Br Med J (Clin Res Ed) 1987 May 30;294(6584):1389–1391. doi: 10.1136/bmj.294.6584.1389. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Callam M. J., Ruckley C. V., Harper D. R., Dale J. J. Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J (Clin Res Ed) 1985 Jun 22;290(6485):1855–1856. doi: 10.1136/bmj.290.6485.1855. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Carley P. J., Wainapel S. F. Electrotherapy for acceleration of wound healing: low intensity direct current. Arch Phys Med Rehabil. 1985 Jul;66(7):443–446. [PubMed] [Google Scholar]
  17. Coleridge Smith P. D., Thomas P., Scurr J. H., Dormandy J. A. Causes of venous ulceration: a new hypothesis. Br Med J (Clin Res Ed) 1988 Jun 18;296(6638):1726–1727. doi: 10.1136/bmj.296.6638.1726. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Cornwall J. V., Doré C. J., Lewis J. D. Leg ulcers: epidemiology and aetiology. Br J Surg. 1986 Sep;73(9):693–696. doi: 10.1002/bjs.1800730905. [DOI] [PubMed] [Google Scholar]
  19. Dale J. J., Callam M. J., Ruckley C. V., Harper D. R., Berrey P. N. Chronic ulcers of the leg: a study of prevalence in a Scottish community. Health Bull (Edinb) 1983 Nov;41(6):310–314. [PubMed] [Google Scholar]
  20. Danielsen L., Westh H., Balselv E., Rosdahl V. T., Döring G. Pseudomonas aeruginosa exotoxin A antibodies in rapidly deteriorating chronic leg ulcers. Lancet. 1996 Jan 27;347(8996):265–265. doi: 10.1016/s0140-6736(96)90442-0. [DOI] [PubMed] [Google Scholar]
  21. Eckman J. R. Leg ulcers in sickle cell disease. Hematol Oncol Clin North Am. 1996 Dec;10(6):1333–1344. doi: 10.1016/s0889-8588(05)70404-4. [DOI] [PubMed] [Google Scholar]
  22. Eklund A. E., Eriksson G., Olsson A. G. A controlled study showing significant short term effect of prostaglandin E1 in healing of ischaemic ulcers of the lower limb in man. Prostaglandins Leukot Med. 1982 Mar;8(3):265–271. doi: 10.1016/0262-1746(82)90049-x. [DOI] [PubMed] [Google Scholar]
  23. Erickson C. A., Nuccitelli R. Embryonic fibroblast motility and orientation can be influenced by physiological electric fields. J Cell Biol. 1984 Jan;98(1):296–307. doi: 10.1083/jcb.98.1.296. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Evans H. A treatment of last resort. Nurs Times. 1997 Jun 4;93(23):62–65. [PubMed] [Google Scholar]
  25. Fahey C. Experience with a new human skin equivalent for healing venous leg ulcers. J Vasc Nurs. 1998 Mar;16(1):11–15. doi: 10.1016/s1062-0303(98)90031-0. [DOI] [PubMed] [Google Scholar]
  26. Falabella A. F., Carson P., Eaglstein W. H., Falanga V. The safety and efficacy of a proteolytic ointment in the treatment of chronic ulcers of the lower extremity. J Am Acad Dermatol. 1998 Nov;39(5 Pt 1):737–740. doi: 10.1016/s0190-9622(98)70045-3. [DOI] [PubMed] [Google Scholar]
  27. Falanga V., Eaglstein W. H. The "trap" hypothesis of venous ulceration. Lancet. 1993 Apr 17;341(8851):1006–1008. doi: 10.1016/0140-6736(93)91085-z. [DOI] [PubMed] [Google Scholar]
  28. Fletcher A., Cullum N., Sheldon T. A. A systematic review of compression treatment for venous leg ulcers. BMJ. 1997 Sep 6;315(7108):576–580. doi: 10.1136/bmj.315.7108.576. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Gault W. R., Gatens P. F., Jr Use of low intensity direct current in management of ischemic skin ulcers. Phys Ther. 1976 Mar;56(3):265–269. doi: 10.1093/ptj/56.3.265. [DOI] [PubMed] [Google Scholar]
  30. Gibbons G. W. The diabetic foot: amputations and drainage of infection. J Vasc Surg. 1987 May;5(5):791–793. doi: 10.1067/mva.1987.avs0050791. [DOI] [PubMed] [Google Scholar]
  31. Hahn J., Jünger M., Friedrich B., Zuder D., Steins A., Hahn M., Klyscz T. Cutaneous inflammation limited to the region of the ulcer in chronic venous insufficiency. Vasa. 1997 Nov;26(4):277–281. [PubMed] [Google Scholar]
  32. Hallbök T. Leg ulcer epidemiology. Acta Chir Scand Suppl. 1988;544:17–20. [PubMed] [Google Scholar]
  33. Hansson C., Andersson E., Swanbeck G. Leg ulcer epidemiology in Gothenburg. Acta Chir Scand Suppl. 1988;544:12–16. [PubMed] [Google Scholar]
  34. Hansson C. The effects of cadexomer iodine paste in the treatment of venous leg ulcers compared with hydrocolloid dressing and paraffin gauze dressing. Cadexomer Iodine Study Group. Int J Dermatol. 1998 May;37(5):390–396. doi: 10.1046/j.1365-4362.1998.00415.x. [DOI] [PubMed] [Google Scholar]
  35. Heng M. C., Pilgrim J. P., Beck F. W. A simplified hyperbaric oxygen technique for leg ulcers. Arch Dermatol. 1984 May;120(5):640–645. [PubMed] [Google Scholar]
  36. Herouy Y., May A. E., Pornschlegel G., Stetter C., Grenz H., Preissner K. T., Schöpf E., Norgauer J., Vanscheidt W. Lipodermatosclerosis is characterized by elevated expression and activation of matrix metalloproteinases: implications for venous ulcer formation. J Invest Dermatol. 1998 Nov;111(5):822–827. doi: 10.1046/j.1523-1747.1998.00369.x. [DOI] [PubMed] [Google Scholar]
  37. Herouy Y., Nockowski P., Schöpf E., Norgauer J. Lipodermatosclerosis and the significance of proteolytic remodeling in the pathogenesis of venous ulceration (Review). Int J Mol Med. 1999 May;3(5):511–515. doi: 10.3892/ijmm.3.5.511. [DOI] [PubMed] [Google Scholar]
  38. Hickie S., Ross S., Bond C. A survey of the management of leg ulcers in primary care settings in Scotland. J Clin Nurs. 1998 Jan;7(1):45–50. doi: 10.1046/j.1365-2702.1998.00124.x. [DOI] [PubMed] [Google Scholar]
  39. Hopkins N. F., Spinks T. J., Rhodes C. G., Ranicar A. S., Jamieson C. W. Positron emission tomography in venous ulceration and liposclerosis: study of regional tissue function. Br Med J (Clin Res Ed) 1983 Jan 29;286(6362):333–336. doi: 10.1136/bmj.286.6362.333. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Hurley J. J., Auer A. I., Hershey F. B., Binnington H. B., Woods J. J., Jr, Nunnelee J. D., Milyard M. K. Distal arterial reconstruction: patency and limb salvage in diabetics. J Vasc Surg. 1987 May;5(5):796–802. [PubMed] [Google Scholar]
  41. Jelinek J. E. Cutaneous manifestations of diabetes mellitus. Int J Dermatol. 1994 Sep;33(9):605–617. doi: 10.1111/j.1365-4362.1994.tb02915.x. [DOI] [PubMed] [Google Scholar]
  42. Johannsen F., Gam A. N., Karlsmark T. Ultrasound therapy in chronic leg ulceration: a meta-analysis. Wound Repair Regen. 1998 Mar-Apr;6(2):121–126. doi: 10.1046/j.1524-475x.1998.60205.x. [DOI] [PubMed] [Google Scholar]
  43. Jude E. B., Boulton A. J., Ferguson M. W., Appleton I. The role of nitric oxide synthase isoforms and arginase in the pathogenesis of diabetic foot ulcers: possible modulatory effects by transforming growth factor beta 1. Diabetologia. 1999 Jun;42(6):748–757. doi: 10.1007/s001250051224. [DOI] [PubMed] [Google Scholar]
  44. Katsarou-Katsari A., Armenaka M., Katsenis K., Papageorgiou M., Katsambas A., Bareltzides A. Contact allergens in patients with leg ulcers. J Eur Acad Dermatol Venereol. 1998 Jul;11(1):9–12. [PubMed] [Google Scholar]
  45. Kolari P. I., Pekanmäki K. Intermittent pneumatic compression in healing of venous ulcers. Lancet. 1986 Nov 8;2(8515):1108–1108. doi: 10.1016/s0140-6736(86)90517-9. [DOI] [PubMed] [Google Scholar]
  46. Layton A. M., Ibbotson S. H., Davies J. A., Goodfield M. J. Randomised trial of oral aspirin for chronic venous leg ulcers. Lancet. 1994 Jul 16;344(8916):164–165. doi: 10.1016/s0140-6736(94)92759-6. [DOI] [PubMed] [Google Scholar]
  47. Lookingbill D. P., Miller S. H., Knowles R. C. Bacteriology of chronic leg ulcers. Arch Dermatol. 1978 Dec;114(12):1765–1768. [PubMed] [Google Scholar]
  48. Loots M. A., Lamme E. N., Zeegelaar J., Mekkes J. R., Bos J. D., Middelkoop E. Differences in cellular infiltrate and extracellular matrix of chronic diabetic and venous ulcers versus acute wounds. J Invest Dermatol. 1998 Nov;111(5):850–857. doi: 10.1046/j.1523-1747.1998.00381.x. [DOI] [PubMed] [Google Scholar]
  49. Maessen-Visch M. B., Hamulyak K., Tazelaar D. J., Crombag N. H., Neumann H. A. The prevalence of factor V Leiden mutation in patients with leg ulcers and venous insufficiency. Arch Dermatol. 1999 Jan;135(1):41–44. doi: 10.1001/archderm.135.1.41. [DOI] [PubMed] [Google Scholar]
  50. Moffatt C. J., Franks P. J. A prerequisite underlining the treatment programme. Risk factors associated with venous disease. Prof Nurse. 1994 Jun;9(9):637-40, 642. [PubMed] [Google Scholar]
  51. Morrell C. J., Walters S. J., Dixon S., Collins K. A., Brereton L. M., Peters J., Brooker C. G. Cost effectiveness of community leg ulcer clinics: randomised controlled trial. BMJ. 1998 May 16;316(7143):1487–1491. doi: 10.1136/bmj.316.7143.1487. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Morykwas M. J., Argenta L. C., Shelton-Brown E. I., McGuirt W. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997 Jun;38(6):553–562. doi: 10.1097/00000637-199706000-00001. [DOI] [PubMed] [Google Scholar]
  53. Nwomeh B. C., Liang H. X., Cohen I. K., Yager D. R. MMP-8 is the predominant collagenase in healing wounds and nonhealing ulcers. J Surg Res. 1999 Feb;81(2):189–195. doi: 10.1006/jsre.1998.5495. [DOI] [PubMed] [Google Scholar]
  54. Oien R. F., Hansen B. U., Håkansson A. Pinch grafting of leg ulcers in primary care. Acta Derm Venereol. 1998 Nov;78(6):438–439. doi: 10.1080/000155598442737. [DOI] [PubMed] [Google Scholar]
  55. Owen J. A., Jr How to treat the diabetic foot. Geriatrics. 1982 Mar;37(3):57-8, 63-4, 69. [PubMed] [Google Scholar]
  56. Peus D., Heit J. A., Pittelkow M. R. Activated protein C resistance caused by factor V gene mutation: common coagulation defect in chronic venous leg ulcers? J Am Acad Dermatol. 1997 Apr;36(4):616–620. doi: 10.1016/s0190-9622(97)70251-2. [DOI] [PubMed] [Google Scholar]
  57. Phillips T. J. Cultured skin grafts. Past, present, future. Arch Dermatol. 1988 Jul;124(7):1035–1038. [PubMed] [Google Scholar]
  58. Phillips T. J., Dover J. S. Leg ulcers. J Am Acad Dermatol. 1991 Dec;25(6 Pt 1):965–987. doi: 10.1016/0190-9622(91)70295-d. [DOI] [PubMed] [Google Scholar]
  59. Phillips T. J., Gilchrest B. A. Cultured allogenic keratinocyte grafts in the management of wound healing: prognostic factors. J Dermatol Surg Oncol. 1989 Nov;15(11):1169–1176. doi: 10.1111/j.1524-4725.1989.tb03230.x. [DOI] [PubMed] [Google Scholar]
  60. Phillips T. J., Kehinde O., Green H., Gilchrest B. A. Treatment of skin ulcers with cultured epidermal allografts. J Am Acad Dermatol. 1989 Aug;21(2 Pt 1):191–199. doi: 10.1016/s0190-9622(89)70160-2. [DOI] [PubMed] [Google Scholar]
  61. Phillips T. J. Successful methods of treating leg ulcers. The tried and true, plus the novel and new. Postgrad Med. 1999 May 1;105(5):159-61, 165-6, 173-4 passim. doi: 10.3810/pgm.1999.05.1.744. [DOI] [PubMed] [Google Scholar]
  62. Remes K., Rönnemaa T. Healing of chronic leg ulcers in diabetic necrobiosis lipoidica with local granulocyte-macrophage colony stimulating factor treatment. J Diabetes Complications. 1999 Mar-Apr;13(2):115–118. doi: 10.1016/s1056-8727(98)00025-7. [DOI] [PubMed] [Google Scholar]
  63. Richmand D. M., O'Donnell T. F., Jr, Zelikovski A. Sequential pneumatic compression for lymphedema. A controlled trial. Arch Surg. 1985 Oct;120(10):1116–1119. doi: 10.1001/archsurg.1985.01390340014002. [DOI] [PubMed] [Google Scholar]
  64. Rowley B. A., McKenna J. M., Chase G. R., Wolcott L. E. The influence of electrical current on an infecting microorganism in wounds. Ann N Y Acad Sci. 1974;238:543–551. doi: 10.1111/j.1749-6632.1974.tb26820.x. [DOI] [PubMed] [Google Scholar]
  65. Sabolinski M. L., Alvarez O., Auletta M., Mulder G., Parenteau N. L. Cultured skin as a 'smart material' for healing wounds: experience in venous ulcers. Biomaterials. 1996 Feb;17(3):311–320. doi: 10.1016/0142-9612(96)85569-4. [DOI] [PubMed] [Google Scholar]
  66. Simon D. A., Freak L., Kinsella A., Walsh J., Lane C., Groarke L., McCollum C. Community leg ulcer clinics: a comparative study in two health authorities. BMJ. 1996 Jun 29;312(7047):1648–1651. doi: 10.1136/bmj.312.7047.1648. [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. Thomas S., Jones M., Shutler S., Andrews A. Wound care. All you need to know about ... maggots. Nurs Times. 1996 Nov 13;92(46):63-6, 68, 70 passim. [PubMed] [Google Scholar]
  68. Van de Scheur M., Falanga V. Pericapillary fibrin cuffs in venous disease. A reappraisal. Dermatol Surg. 1997 Oct;23(10):955–959. doi: 10.1111/j.1524-4725.1997.tb00759.x. [DOI] [PubMed] [Google Scholar]
  69. Villeneuve P., Hafner J., Prenosil J. E., Elsner P., Burg G. A novel culturing and grafting system for the treatment of leg ulcers. Br J Dermatol. 1998 May;138(5):849–851. doi: 10.1046/j.1365-2133.1998.02224.x. [DOI] [PubMed] [Google Scholar]
  70. Voinchet V., Magalon G. Le vacuum assisted closure. La cicatrisation par pression d'air négative. Ann Chir Plast Esthet. 1996 Oct;41(5):583–589. [PubMed] [Google Scholar]
  71. Wertheim D., Melhuish J., Williams R., Harding K. Measurement of forces associated with compression therapy. Med Biol Eng Comput. 1999 Jan;37(1):31–34. doi: 10.1007/BF02513262. [DOI] [PubMed] [Google Scholar]
  72. Wilkinson E. A., Hawke C. I. Does oral zinc aid the healing of chronic leg ulcers? A systematic literature review. Arch Dermatol. 1998 Dec;134(12):1556–1560. doi: 10.1001/archderm.134.12.1556. [DOI] [PubMed] [Google Scholar]
  73. Young J. R. Differential diagnosis of leg ulcers. Cardiovasc Clin. 1983;13(2):171–193. [PubMed] [Google Scholar]
  74. Zelikovski A., Deutsch A., Reiss R. The sequential pneumatic compression device in surgery for lymphedema of the limbs. J Cardiovasc Surg (Torino) 1983 Mar-Apr;24(2):122–126. [PubMed] [Google Scholar]

Articles from Postgraduate Medical Journal are provided here courtesy of BMJ Publishing Group

RESOURCES