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Leg Ulcer

Checked: 23-11-2021 by Vicky Ryan Next Review: 23-11-2021

Overview

Leg ulcers are of huge socio-economic importance costing the NHS over one billion pounds per year. There are in excess of 100,000 active venous ulcers in the UK at any one time, 80% of these have treatment that is based in the community. A leg ulcer is not a diagnosis; it is a manifestation of an underlying disease process. (1)

Aetiology

Venous - 70-80%
Arterial - 10% - see the Arterial leg ulcer page
Mixed venous/arterial - 10-20%
Neuropathic (usually due to diabetes) - if on the foot then see the Diabetic Foot Care page
Other causes e.g. Vasculitis, rheumatoid disease, malignancy.

Assessment and diagnosis

History

A full medical history needs to be obtained with particular respect given to co-morbidities, smoking history, nutrition, and dehydration.

Medication - drugs such as beta-blockers, steroids, NSAIDs and immunosuppressive agents can all adversely influence ulcer healing. Nicorandil can both cause ulcers and delay healing.

Examination

Clinical examination may reveal typical features of venous or arterial ulcers. Please see the PCDS Leg Ulcer page for further details and pictures.

Investigations

Bloods - check FBC, UE, LFT, TFT, HbA1c, lipids.

Doppler and ABPI assessment - all patient’s presenting with a lower leg wound that has failed to heal within 2 weeks require a lower limb and Doppler assessment to identify the aetiology of the wound and detect any underlying arterial disease. Compression should not be applied until a full assessment and ABPI has taken place

The Doppler assessment is part of the lower limb assessment and should not be used alone. The local wound care team advise interpretation of results as below:

ABPI 0.8-1.3 – likely to be venous aetiology and suitable for full compression (40mmHg)
ABPI 0.65-0.79 – likely to be mixed aetiology – suitable for reduced compression (20mmHg)
ABPI less than 0.64 – refer to Wound Care Service
ABPI less than 0.5 – Urgent referral to vascular.
ABPI more than 1.3 – refer to Wound Care Service.

Biopsy - consider referral to the Community Dermatology Service or secondary care dermatologist if the diagnosis is in doubt for consideration of biopsy. Please attach good quality pictures. Alternatively you use the Dermatology Advice and Guidance service.

Red Flags

Chronic leg ulceration may also be caused by skin cancer. If malignant change in an ulcer is suspected then refer to dermatology 2WW pathway

Patients with infected diabetic foot ulcers should be referred immediately to the Vascular Hot Clinic.

Referral

Venous Leg Ulcers

Most venous leg ulcers should be managed by the practice nurse team or by district nurses if a patient is housebound.

The BNSSG Wound Care Service (tissue viability service) can provide support for practice nurses and district nurses who are managing difficult wounds and leg ulcers. In particular consider referral to the wound care service for the following:

Diabetic patients / neuropathic ulcers
Ulcers secondary to systemic diseases, eg systemic sclerosis, vasculitis, rheumatoid arthritis, Uncontrolled cardiac failure, suspected pyoderma gangrenosum.

If persistent venous leg ulcers do not respond to treatment after 6 months, or if there are 2 or more episodes of recurrence of venous ulceration within a 12 month period, then referral should be made - please see the Varicose Veins and Venous Leg Ulcers page for details.

Patients with non-vascular leg ulceration that are not responding to treatment in primary care can be referred to the general dermatology clinics via e-RS (please include pictures).

Foot Ulcers

The Podiatry Service can manage patients with foot ulcers who are at moderate/high risk. The links have referral guidelines and referral forms as well as contact details.

Arterial Leg Ulcers

Please see the Arterial leg ulcer page.

Diabetic Foot Ulcers

See the Diabetic Foot Care pathway

Resources

(1) Leg Ulcers. Primary Care Dermatology Society.

(2) Varicose veins | CKS

Resources

Diabetic Foot Care pathway

Venous ulcer management as provided by NICE: cks.nice.org.uk/leg-ulcer-venous

Prescribing: NICE Guidance: Leg Ulcer Infection; Antimicrobial prescribing guideline.

Leg ulcer support group:

The Lindsay leg club Foundation: www.legclub.org/

Please see the Tissue Viability / Wound Care Service page for further Leg Ulcer resources.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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