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Leg ulcer - venous - Management
What follow up is required during treatment of a venous ulcer? 

  • Ideally, uncomplicated ulcers should be assessed at least weekly for the first 2 weeks. If healing is underway this can be extended to fortnightly or monthly, and then 3-monthly intervals thereafter. If there are any concerns about ulcer deterioration, then more regular inspection is needed.
  • Dressings should be changed at least once a week. At the same time check for healing and compliance with compression therapy and ask about problems (mobility, sleep, mood, and independence).
    • Ideally, when compression therapy is started, people should be re-assessed for skin complications within 24–48 hours.
  • If there is delayed or no healing, identify problems which may need further treatment or referral:
    • Assess how the person's age, mobility, diet, medication (immunosuppressive drugs), and co-morbidities (e.g. diabetes) may be influencing healing.
    • Look for granulation, or fibrous or necrotic tissue and slough:
      • Healthy granulation tissue is pink in colour (suggests healing).
      • Unhealthy granulation tissue is dark red in colour, and often bleeds on contact (may suggest infection).
      • Fibrous tissue (white or yellow shiny), eschar (dry, black necrotic tissue), or slough (cream coloured) indicates that the wound may require debridement.
    • Look for varicose veins which may need surgery.
    • Check for complications related to:
      • The ulcer: cellulitis as well as sinus formation and fistula (both uncommon).
      • Compression bandaging: pressure damage or arterial insufficiency. Compression bandages should be removed immediately if the person experiences a change in foot colour or temperature, or increased pain. Consider seeking further medical advice if there is no improvement after removing the bandages.
      • The dressings applied: skin maceration or allergic contact dermatitis. Maceration is indicated by a marked cut off appearance. It is usually caused by the inability of the dressing to manage exudate, so consider more frequent dressing changes, or a change in dressing type, and protect the surrounding skin with the use of an emollient.
    • Ask the person if they are adhering to lifestyle strategies such as elevating legs, limb exercises, regular walking, and losing weight (if needed).
  • If the ulcer is not fully healed or deteriorating at 12 weeks, look for signs of arterial insufficiency and repeat Doppler studies, and refer.
Clarification / Additional information
  • Inspect and compare the ulcer with the initial assessment to see if there is evidence of healing. Healing is suggested by reduced ulcer size, development of healthy pink granulation tissue, reduced amounts of exudate, and improved symptoms of pain and oedema.
  • Poor compliance with compression therapy can be due to heat, discomfort, and the impractical nature of the bandaging. The healthcare professional should be aware of these issues and explain the importance of compliance.
  • Education regarding ulcer disease, rationale for treatment, and lifestyle strategies should be delivered at every possible occasion, and should be appropriate to the person's stage of treatment.
Basis for recommendation
  • These recommendations are based on clinical guidelines: The nursing management of patients with venous leg ulcers published by the Royal College of Nursing (RCN) [RCN, 2006], and Management of chronic venous leg ulcers published by the Scottish Intercollegiate Guidelines Network SIGN [SIGN, 2010], together with the best available trial evidence, informed expert opinion, and current good clinical practice:
  • Assessing and following up people with ulcers in a structured way will allow the identification of factors that might be having an impact on treatment and the healing process. The RCN guidelines reviewed good quality prospective epidemiological studies which showed that ulcer duration, size at presentation, and change in size during early treatment best predicts the healing rate of ulcers treated with compression bandaging [RCN, 2006].

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