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Leg ulcer - venous - Management
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Overview of management

  • All people with venous leg ulcers should be managed by a healthcare professional trained in leg ulcer management. Most venous leg ulcers can be managed in primary care.
  • Referral is usually considered if there is an uncertain diagnosis, treatment failure, or if complications develop.
  • All people with venous leg ulcers should be assessed for arterial insufficiency by Doppler studies, oedema, venous eczema, and examined for signs of infection.
  • Manage an uncomplicated venous leg ulcer by cleaning with tap water (or saline), dressing with a simple low-adherent dressing, and applying a 4-layer or 2-layer compression bandage.
  • Manage an infected venous leg ulcer by first cleaning the wound and taking a swab. Then apply a simple low-adherent dressing and prescribe an empirical course of antibiotics (flucloxacillin). Do not use compression bandaging until the infection has resolved.
  • Advise people about adopting a lifestyle that encourages healing and prevents recurrence of the ulcer.
  • When the ulcer has healed, people should be encouraged to wear below knee class III graduated compression stockings if they are not contraindicated and can be tolerated, to prevent ulcer recurrence. This should be encouraged for a minimum of 5 years (although life long usage is preferable).
  • If the ulcer fails to heal and complications have been excluded in secondary care, aim to improve the person's quality of life rather than heal the ulcer, as healing of the ulcer may not be an achievable outcome.
  • Manage associated pain with simple analgesia, encourage leg elevation to reduce oedema, and use regular emollients plus a low-potency topical corticosteroid (after exclusion of cellulitis) for venous eczema.
  • Exclude contact dermatitis related to dressings if skin rash worsens when applying dressings at any stage of treatment, and refer to Dermatology for consideration of patch testing.
  • Follow up an infected ulcer daily or every other day until the infection has resolved. Weekly to monthly reviews are then appropriate for uncomplicated venous ulcers until the ulcer heals. During follow up look for possible complications related to the ulcer and treatment. Assess the impact that symptoms are having on the person's quality of life and look for risk factors and comorbidities which need treatment or referral.

How do I assess a person with a venous leg ulcer?

  • An assessment should be carried out by a healthcare professional trained in leg ulcer management.
  • Carry out Doppler studies to exclude arterial insufficiency.
  • Ask about pain (site, nature, severity), odour, and discharge.
  • Examine the legs for oedema, venous eczema and varicose veins.
  • Look for signs of an infected leg ulcer such as:
    • Enlarging ulcer.
    • Increased exudate.
    • Increased pain.
    • Pyrexia.
    • Foul odour.
    • Cellulitis: surrounding skin is red, hot and non-scaling.
  • Inspect and record details about the ulcer, to compare at follow up in order to determine how well the ulcer is healing. Assess:
    • Size and depth — trace out the ulcer margin onto a transparent sheet, or if possible and appropriate, a photograph may be helpful. Examine to assess the depth of the ulcer.
    • Wound bed — look for fibrous or necrotic tissue which may need to be removed to allow healing. Look for signs of healthy granulation tissue. Look for exudate to help determine which dressing is needed.
    • The ulcer edge often give a good indication of progress and should be carefully documented (for example shallow, epithelialising, punched out).
    • The position of the ulcer(s) should be clearly described.
  • Assess the impact that the symptoms are having on the person's quality of life. For example, can they move around and carry out normal activities of daily living such as shopping, housework, or employment?
  • Assess risk factors (such as immobility or obesity) and comorbidities (such as diabetes mellitus or rheumatoid arthritis) which need treatment or referral to promote ulcer healing.
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, 2006] and the Scottish Intercollegiate Guidelines Network guideline Management of chronic venous leg ulcers [SIGN, 2010], together with the best available trial evidence, informed expert opinion, and current good clinical practice.
  • Lack of appropriate clinical assessment in the community of people with limb ulceration has often led to long periods of ineffective and even inappropriate treatment. A thorough assessment, as suggested, will help identify both the underlying cause and any associated conditions, and will influence decisions about prognosis, referral, and management [RCN, 2006].
  • Assessing serial measurement of the surface area: this is important as it is a reliable index of ulcer healing [SIGN, 2010].
  • Assessing the depth of leg ulcer: this is important as deep ulcers involving deep fascia, tendon, periosteum or bone may have an arterial component [SIGN, 2010].

How do I interpret Doppler studies?

  • A Doppler assessment of both legs and interpretation should be carried out on all people by an appropriately trained healthcare professional.
  • An ankle brachial pressure index (ABPI) involves the measurement of a person's systolic blood pressure at their ankle and arm (brachial) using a Doppler machine. The ABPI provides an index of vessel competency by measuring the ratio of systolic blood pressure at the ankle to that in the arm, with a value of 1 being normal. When interpreting ABPI in a person with venous ulcer, a ratio of:
    • Less than 0.5 indicates severe arterial insufficiency and compression treatment is contraindicated. Refer urgently to a specialist vascular clinic for further assessment.
    • Between 0.5 and 0.8 indicates that the person has arterial disease. Refer to a specialist vascular clinic for further assessment. Compression bandaging should generally be avoided. However, reduced compression can be used under strict supervision (assess progress daily) if the ulcer is clinically venous and the healthcare professional has sufficient experience.
    • Greater than 0.8 indicates that graduated compression bandages may be safely applied.
  • Be aware that the ABPI may decrease after the initial measurement. Arterial disease may develop in people with venous disease, and the ABPI will also reduce with increasing age.
  • People with diabetes mellitus, atherosclerotic disease, rheumatoid arthritis, and systemic vasculitis should be referred for specialist assessment as the ABPI in these people may not be reliable. These conditions may give falsely high (and misleading) ABPI readings due to calcification of the blood vessels.
Clarification / Additional information
  • A Doppler assessment measuring the ankle brachial pressure index (ABPI) should be carried out on all people with venous leg ulceration at:
    • The initial presentation.
    • Twelve weeks if there are signs of delayed or poor healing, and then at 3-monthly intervals until the ulcer has healed.
    • Six-monthly intervals when compression stockings are being used to prevent recurrent venous ulceration.
    • The first signs of ulcer deterioration, ulcer recurrence, sudden increase in ulcer size or pain, or change in foot colour or temperature.
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, 2006], and a guideline from the Scottish Intercollegiate Guidelines Network Management of chronic venous leg ulcers [SIGN, 2010], together with the best available trial evidence, informed expert opinion, and current good clinical practice.
  • An ankle brachial pressure index (ABPI) of < 0.9 is considered to be abnormal, and this cut-off has been shown in several clinical studies to be highly sensitive and specific for detecting peripheral arterial disease (positive predictive value of 95% and negative predictive value of 99%) [SIGN, 2010].
  • The Royal College of Nursing based their Doppler studies recommendations on a number of cohort and cross-sectional studies. Applying a compression bandage to a limb that has arterial insufficiency could lead to pressure damage, limb ischaemia, and even amputation [RCN, 2006].

When should I refer someone with a venous leg ulcer?

  • All people should be managed by a healthcare professional who is trained in the management of venous leg ulcers.
  • Many primary care teams will have expertise in managing venous leg ulcers via appropriately trained practice nurses or district nurses. A referral to other services (secondary care) is often only necessary if there is an uncertain diagnosis, or a person does not respond to treatment in primary care, or complications develop.
  • Refer a person to secondary care before treatment if there is:
    • An uncertain diagnosis.
    • A suspected alternative cause of ulceration:
      • Arterial or mixed venous/arterial ulcer: refer people with an ankle brachial pressure index (ABPI) of less than or equal to 0.8 to a specialist vascular clinic for further assessment of arterial disease. If the ABPI is less than 0.5, refer urgently.
      • Suspected malignant ulcer, rapidly deteriorating ulcer, an atypical appearance or distribution of ulcers — refer to Dermatology for possible biopsy.
      • An ulcer associated with rheumatoid arthritis, or ulcers associated with systemic vasculitis.
      • An ulcer associated with diabetes mellitus, or the person has newly diagnosed diabetes mellitus.
  • Refer a person to secondary care during treatment if there is:
    • A complication related to the ulcer or treatment:
      • Suspected contact dermatitis — refer to Dermatology for patch testing using a leg ulcer series.
      • Cellulitis requiring intravenous antibiotics or cellulitis worsening despite treatment.
      • Pain which is uncontrolled — refer to a specialist pain team.
    • A non-healing or worsening ulcer after 2–3 months of standard treatment.
    • A Recurrent ulcer.
    • A condition which needs specialist assessment and intervention such as varicose veins or arterial insufficiency.
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 the Scottish Intercollegiate Guidelines Network guideline Management of chronic venous leg ulcers [SIGN, 2010], together with the best available trial evidence, informed expert opinion, and current good clinical practice.
  • A co-ordinated multidisciplinary team approach is vital, as a variety of healthcare professionals including practice nurses, district nurses, general practitioners, dermatology specialist nurses and teams, and vascular teams may be involved. Direct access to specialized hospital services is vital in the management of specific complications.
  • The RCN guideline found no studies that specifically examined the outcomes of people with leg ulcers referred from primary to secondary care, or between healthcare professionals in primary care. The recommendations are therefore largely based on expert opinion [RCN, 2006].
  • Community leg ulcer clinics may significantly improve healing and recurrence rates, and are more cost effective when they have close liaison with secondary care [NHS CRD, 1997; SIGN, 2010].
  • Leg ulcer nurse specialists in dedicated clinics can promote and maintain standards of care and cost effectiveness [Simon et al, 2004].
  • The incidence of contact allergy increases with the duration of ulceration, and several large patch test studies have shown that the principal sensitizers are ingredients of applications, dressings, and bandages [SIGN, 2010].

What lifestyle advice is needed for someone with a venous leg ulcer?

  • Advise the person to consider the following self-care strategies, both when they have an ulcer and after the ulcer has healed:
    • Keep mobile with regular walking. Elevate legs when immobile.
    • Avoid trauma and wear appropriate (well-fitting) footwear.
    • Use an emollient frequently even after the ulcer has healed (avoid products that may contain sensitizing agents).
    • Examine legs regularly for broken skin, blisters, swelling, or redness.
    • Wear compression bandages or stockings as advised. If there are any difficulties, contact a healthcare professional before stopping using them.
  • Advise the person to adopt a healthy lifestyle to promote healing and prevent recurrence of ulcers:
    • Lose weight (if appropriate), eat a balanced diet, and drink alcohol at sensible levels. See the CKS topics on Obesity and Alcohol - problem drinking for more information.
    • Stop smoking: if the person is willing to quit refer them to smoking cessation services. See the CKS topic on Smoking cessation for more information.
  • Provide advice about local organizations that can provide support, such as www.legclub.org.
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, 2006], together with the best available trial evidence, informed expert opinion, and current good clinical practice.
  • There is very little evidence on the effectiveness of self-care and lifestyle strategies on the healing and recurrence rates of venous leg ulcers. The recommendations are based on best practice and clinical common sense. Advice should be given in the context of improving the person's overall health and quality of life [Dutch College of General Practitioners, 2004; RCN, 2006].
  • Stopping smoking:
    • CKS recommends stopping smoking because nicotine is a vasoconstrictor and adversely affects the microcirculation, leading to impaired wound healing.

How do I manage an uncomplicated venous leg ulcer?

How should I clean a venous ulcer?

  • Irrigate the ulcer at each dressing change with warm tap water or saline, then dry. A strict aseptic technique is not required.
  • Debridement is not usually necessary: any slough, or necrotic, fibrous, or excess granulation tissue should be removed by gentle washing. If debridement is being considered, the procedure should be carried out by a trained healthcare professional.
  • Consider using a potassium permanganate 0.01% soak if the ulcer is malodorous.
Clarification / Additional information
  • Debridement techniques include mechanical, autolytic, chemical, bio-surgical (maggots), or enzymatic methods. However, there is consensus that chemical agents such as iodine, acetic acid, hydrogen peroxide, or hypochlorite should not be used.
  • Sharp debridement (at the bed side) should only be carried out by a trained healthcare professional and a topical anaesthetic (e.g. EMLA® cream) is normally used to reduce pain.
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 the Scottish Intercollegiate Guidelines Network (SIGN) clinical guideline Management of chronic venous leg ulcers [SIGN, 2010], together with the best available trial evidence, informed expert opinion, and current good clinical practice.
  • Irrigation:
    • The aim is not to remove surface bacteria, but rather to avoid cross-infection from contamination.
    • The SIGN guideline recommends washing ulcerated legs normally in tap water and drying carefully.
    • The RCN guideline found no trials comparing aseptic with clean techniques for cleaning leg ulcers. A systematic review (search date May 2001, six randomized controlled trials [RCTs], n = 1864) suggested there was a lack of evidence for or against cleaning leg ulcers versus not cleaning, cleaning with tap water versus cleaning with saline, and cleaning with antiseptics [RCN, 2006].
  • Debridement:
    • Sharp mechanical debridement (with a scalpel or sharp blade) should only be undertaken by an appropriately trained healthcare professional [SIGN, 2010], and may delay healing because of the risk of damaging healthy tissue and underlying blood vessels [Briggs and Nelson, 2003].
    • The SIGN guideline found a double blind placebo controlled trial of 69 people using EMLA® as a topical anaesthetic for the repeated mechanical debridement of venous ulcers. It found that wounds were cleaned faster and pain relief was better, but no comparisons were made with other therapies. This is an off-label indication for the use of EMLA® cream [SIGN, 2010].
    • The RCN guideline reviewed one systematic review (search date October 1997) and three subsequent RCTs, and concluded there is no clear evidence as to the optimal method for debridement. It is not clear whether debridement speeds up ulcer healing compared with no debridement [RCN, 2006; SIGN, 2010].
  • Potassium permanganate soaks are helpful for malodorous ulcers because they have antiseptic and astringent properties [Bell, Personal Communication, 2008].

How should I dress a venous leg ulcer?

  • Dressings and compression therapy should be applied by a healthcare professional trained in venous ulcer management.
  • Wound dressing: apply a low-adherent dressing and replace weekly:
    • If the wound has a heavy exudate, more frequent bandage changes may be required.
    • Alternative dressings may be considered to help with pain (hydrocolloid), heavy exudate (alginate), or slough (hydrogels).
  • Compression therapy: measure the person's ankle circumference and apply below-knee, graduated multi-layer high compression bandaging and replace weekly:
    • For people who are immobile, 4-layer or 3-layer bandaging is more suitable.
    • For people who are mobile, 2-layer bandaging is more practical.
    • Do not use compression therapy if Doppler studies show an ankle brachial pressure index of 0.8 or less, or there is active phlebitis, deep vein thrombosis, or cellulitis.
    • Do not routinely use intermittent pneumatic compression, either as a replacement for, or an adjunct to, compression bandaging.
Clarification / Additional information
  • Wound dressings that create and maintain a clean, moist microenvironment are optimal for wound healing.
  • Compression bandaging is the gold standard treatment for venous leg ulcers. The bandage types are classified depending on the degree of sub-bandage pressure they exert on the limb. A constant tension is needed when applying the bandaging, to create a sub-bandage pressure gradient; the highest pressure is at the ankle, and progressively reduces towards the knee and thigh. Careful attention is needed to avoid the risk of pressure ulceration over bony points.
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 the Scottish Intercollegiate Guidelines Network (SIGN) clinical guideline Management of chronic venous leg ulcers [SIGN, 2010],together with the best available trial evidence, informed expert opinion, and current good clinical practice.
  • Wound dressings aid healing, improve comfort, and control exudate, and are needed to prevent a bandage or compression hosiery from adhering to the wound [SIGN, 2010]. Their role in maintaining moisture facilitates autolytic debridement and promotes healing [Jones et al, 2006]. There is insufficient evidence to show that any wound dressing is better than simple low-adherent dressings for the healing of venous leg ulcers [Palfreyman et al, 2006; RCN, 2006; SIGN, 2010].
  • Graduated compression reduces venous reflux and ankle oedema and increases venous blood flow, thus improving the microcirculation and encouraging the healing process [Rajendran et al, 2007].
    • The RCN guidelines reviewed the available evidence. The trials included were small and considered to be of poor quality. There appeared to be no difference in healing rates between the different types of high compression multilayered systems (4-layered, 3-layered, short-stretch bandages) [Nelson et al, 2006; RCN, 2006].
    • There is no clear evidence that intermittent pneumatic compression improves ulcer healing when compared with standard compression alone, or when added to standard compression regimens. Further research is needed [Mani et al, 2001; RCN, 2006].

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].

How do I manage a suspected infected venous leg ulcer?

How should I clean a venous ulcer?

  • Irrigate the ulcer at each dressing change with warm tap water or saline, then dry. A strict aseptic technique is not required.
  • Debridement is not usually necessary: any slough, or necrotic, fibrous, or excess granulation tissue should be removed by gentle washing. If debridement is being considered, the procedure should be carried out by a trained healthcare professional.
  • Consider using a potassium permanganate 0.01% soak if the ulcer is malodorous.
Clarification / Additional information
  • Debridement techniques include mechanical, autolytic, chemical, bio-surgical (maggots), or enzymatic methods. However, there is consensus that chemical agents such as iodine, acetic acid, hydrogen peroxide, or hypochlorite should not be used.
  • Sharp debridement (at the bed side) should only be carried out by a trained healthcare professional and a topical anaesthetic (e.g. EMLA® cream) is normally used to reduce pain.
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 the Scottish Intercollegiate Guidelines Network (SIGN) clinical guideline Management of chronic venous leg ulcers [SIGN, 2010], together with the best available trial evidence, informed expert opinion, and current good clinical practice.
  • Irrigation:
    • The aim is not to remove surface bacteria, but rather to avoid cross-infection from contamination.
    • The SIGN guideline recommends washing ulcerated legs normally in tap water and drying carefully.
    • The RCN guideline found no trials comparing aseptic with clean techniques for cleaning leg ulcers. A systematic review (search date May 2001, six randomized controlled trials [RCTs], n = 1864) suggested there was a lack of evidence for or against cleaning leg ulcers versus not cleaning, cleaning with tap water versus cleaning with saline, and cleaning with antiseptics [RCN, 2006].
  • Debridement:
    • Sharp mechanical debridement (with a scalpel or sharp blade) should only be undertaken by an appropriately trained healthcare professional [SIGN, 2010], and may delay healing because of the risk of damaging healthy tissue and underlying blood vessels [Briggs and Nelson, 2003].
    • The SIGN guideline found a double blind placebo controlled trial of 69 people using EMLA® as a topical anaesthetic for the repeated mechanical debridement of venous ulcers. It found that wounds were cleaned faster and pain relief was better, but no comparisons were made with other therapies. This is an off-label indication for the use of EMLA® cream [SIGN, 2010].
    • The RCN guideline reviewed one systematic review (search date October 1997) and three subsequent RCTs, and concluded there is no clear evidence as to the optimal method for debridement. It is not clear whether debridement speeds up ulcer healing compared with no debridement [RCN, 2006; SIGN, 2010].
  • Potassium permanganate soaks are helpful for malodorous ulcers because they have antiseptic and astringent properties [Bell, Personal Communication, 2008].

When should I take a wound swab for an infected venous leg ulcer?

  • Take a swab for all suspected infected venous leg ulcers before prescribing an antibiotic.
  • Clean the infected ulcer with tap water or saline prior to taking the swab.
  • Note that venous leg ulcers should not routinely be swabbed unless there is clinical evidence of infection.
Clarification / Additional information
  • Ideally, clean the ulcer with tap water or saline first, and remove unhealthy tissue. Then place the swab onto viable tissue displaying signs of infection and rotate gently to pick up any loose material.
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], Management of chronic venous leg ulcers published by the Scottish Intercollegiate Guidelines Network (SIGN) [SIGN, 2010], and guidelines from the Health Protection Agency (HPA) [HPA, 2006].
  • The HPA recommends taking wound swabs from clinically infected ulcers before starting antibiotics. Taking swabs after starting antibiotics may affect the swab results. Although swabs alone cannot determine the presence of an infection due to the high number of colonized bacteria, sensitivity results can help guide the appropriate use of further antibiotics if the ulcer is not clinically improving on empirical treatment.
  • There is no evidence for the routine use of wound swabs in the management of uncomplicated ulcers, as all venous leg ulcers will be colonized by bacteria at some point, and colonization in itself is not associated with delayed healing [SIGN, 2010]. The RCN based their recommendations on one randomized controlled trial and one prospective study. The studies were considered small, and further research is recommended [RCN, 2006].

How should I dress an infected venous leg ulcer?

  • Dressings should be applied by a healthcare professional trained in venous ulcer management.
  • Wound dressing: apply a low-adherent dressing and replace on a daily basis to assess whether the infection is improving:
    • Alternative dressings may be considered to help with pain (hydrocolloid), heavy exudate (alginate), or slough (hydrogels).
    • Do not use antimicrobial dressings.
  • Compression therapy: do not start compression therapy if the ulcer is infected. If a leg ulcer becomes infected and compression bandaging is being used, remove the bandaging, and restart compression therapy once the infection has resolved.
Clarification / Additional information
  • Wound dressings that create and maintain a clean, moist microenvironment are now considered optimal for wound healing. Low adherent dressings are cheap and widely available. Their major function is to allow exudate to pass through into a secondary dressing while maintaining a moist wound bed to facilitate healing.
  • Compression therapy should preferably be removed if the ulcer becomes infected. Compression therapy may be too painful for an infected ulcer that is already tender, and the daily inspection needed will make compression bandaging impractical.
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, 2006], together with the best available trial evidence and informed expert opinion, and reflects current good clinical practice.
  • Wound dressings aid healing, improve comfort, and control exudate. Their role in maintaining moisture facilitates autolytic debridement and promotes healing [Jones et al, 2006]. There is insufficient evidence to show that any wound dressing (including dressings impregnated with silver) is better than simple low-adherent dressings for the healing of venous leg ulcers [Palfreyman et al, 2006; RCN, 2006].

Which antibiotic should I prescribe?

  • Prescribe flucloxacillin (or erythromycin or clarithromycin if the person is allergic to penicillin) for 7 days, whilst awaiting swab results.
  • Do not use topical antibiotics.
Clarification / Additional information
  • The organisms most likely to be involved in cellulitis include Staphylococcus aureus, MRSA (methicillin-resistant Staphylococcus aureus), and group A beta-haemolytic streptococci. Anaerobes may sometimes be involved. For more information, see the CKS topic on Cellulitis - acute.
Basis for recommendation
  • The following recommendations are based on clinical guidelines: The nursing management of patients with venous leg ulcers published by the Royal College of Nursing [RCN, 2006], and guidelines from the Health Protection Agency (HPA) [HPA, 2006].
  • Antibiotics generally have little effect on wound healing [O'Meara et al, 2000]. There is no value in using antibiotics to treat organisms that have colonized a wound (if they are not causing clinical signs or symptoms of infection) as bacterial contamination is not considered to adversely affect healing [RCN, 1998; O'Meara and Ovington, 2002; SIGN, 2010].
  • Choice of antibiotic:
    • There is little evidence to guide the choice of antibiotic in the treatment of cellulitis [DTB, 2003; Morris, 2006]. For more information, see the CKS topic on Cellulitis - acute.
    • Flucloxacillin is recommended because it is active against most susceptible Gram-positive cocci, including beta-lactamase producing staphylococci and streptococci. It penetrates well into most tissues, so is suitable for skin and soft tissue infections [Finch et al, 2003].
    • Erythromycin and clarithromycin are recommended because they have a broad spectrum of activity and are active against most sensitive Gram-positive cocci (including staphylococci and streptococci) and some Gram-negative cocci and anaerobes [Finch et al, 2003].
    • Clarithromycin may be used in people who are known not to tolerate erythromycin, as it has fewer gastrointestinal adverse effects [Finch et al, 2003].
  • Topical antibiotics are frequent sensitizers and should be avoided [SIGN, 2010].

What follow up is needed for an infected venous leg ulcer?

  • Review the person within 3 days to ensure the infected ulcer is responding to treatment. Ideally, people with infected venous leg ulcers should be followed up daily or every 2–3 days until a clinical improvement is seen.
  • Inspect and compare the ulcer and surrounding skin for signs of improvement, suggested by reduced inflammation, development of healthy pink granulation tissue, reducing exudate, and improving symptoms of pain, oedema, and pyrexia.
  • If the infection is not responding, check swab results and consider changing the antibiotic based on sensitivity information. Consider possible complications or allergic contact dermatitis as a cause for the ongoing symptoms.
  • If the infection is sensitive to the empirical antibiotic but only slowly responding and not deteriorating, review after 7 days and consider continuing the antibiotic for a further 7 days.
  • If there are signs of worsening infection (spreading redness, increasing pain, and systemically unwell), consider osteomyelitis or septicaemia, and admit the person to hospital for intravenous antibiotics.
  • After the infection has settled, follow up the person as for an uncomplicated venous ulcer.
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, 2006], together with the best available trial evidence and informed expert opinion, and reflects current good clinical practice.

How do I manage associated symptoms?

How do I manage a venous leg ulcer with associated dermatitis?

  • Exclude cellulitis if there is worsening venous eczema and signs suggestive of active infection.
  • Use an emollient and a mild to moderate potency topical corticosteroid ointment. If compression bandaging is being used, consider replacing bandages more frequently than once weekly to apply topical treatment. For more information see the CKS topic on Eczema - atopic.
  • If there is no improvement with an emollient and a moderately potent topical corticosteroid, or there are concerns about allergic contact dermatitis (worsening rash with topical treatment at any stage), refer the person to Dermatology for consideration of patch testing, and advise them to avoid any allergens subsequently identified.
Clarification / Additional information
  • Contact dermatitis caused by bandages is well demarcated (i.e. stops where the bandage stops).
  • Common sensitizers include wool alcohols (lanolin), topical antibiotics, topical corticosteroids, cetyl stearyl alcohols, parabens, and rubber mixes. For more information see Issues to consider before prescribing.
Table 1. Features of venous eczema and cellulitis.
Features
Venous eczema
Cellulitis
History
Chronic (usually)
Insidious (24–72 hours)
Appearance
Red, painful to touch, haemosiderin pigmentation
Red, warm, tender to touch
Rash margin
Diffuse (poorly demarcated)
Well demarcated
Symptoms
Itchy
Not itchy, person is systemically unwell, pyrexia
Scaling
Yes
No
Data from: [Grey et al, 2006b]
Basis for recommendation
  • These recommendations are based on the clinical guidelines: The nursing management of patients with venous leg ulcers published by the Royal College of Nursing [RCN, 2006], 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.
  • People can become sensitized to components of their topical treatment at any time. One randomized controlled trial (RCT) suggested that more than 20% of people previously patch tested had developed at least one new allergy at retesting 2–8 years later [RCN, 2006].
  • As there are no RCTs evaluating the impact of patch testing and avoidance policies on ulcer healing, the recommendations are based on expert opinion [RCN, 2006].

How do I manage oedema associated with venous leg ulcers?

  • In addition to compression bandaging (if appropriate), advise the person to elevate their legs (above hip level) for 30 minutes, three to four times a day, and consider placing pillows under their feet and legs while sleeping.
  • Do not prescribe diuretic medication for persistent or worsening oedema: check compliance with advice given regarding reducing oedema, and exclude other causes of oedema such as medication and heart failure.
Clarification / Additional information
  • Prolonged periods of time with legs down (e.g. sitting, standing) as opposed to elevated, and immobility, all contribute to leg oedema.
  • Bed rest and elevation may reduce oedema of the ankle and leg before compression bandages are applied.
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, 2006], together with the best available trial evidence, informed expert opinion, and current good clinical practice [Simon et al, 2004].
  • Leg elevation encourages venous return and may reduce pain and leg swelling.
  • Diuretics are not beneficial for dependent leg oedema and may result in renal impairment. Nevertheless, diuretics may be indicated for oedema related to other causes such as heart failure. For more information see the CKS topic on Heart failure - chronic.

How do I manage pain associated with a venous leg ulcer?

  • Determine the duration, nature, and severity of the pain to exclude an additional cause. Worsening pain may indicate poor ulcer healing, arterial disease, diabetic neuropathy, or cellulitis.
  • Advise the person that leg elevation will help with the pain associated with oedema.
  • Prescribe paracetamol or a combination of paracetamol and codeine phosphate according to the severity of pain and the person's response to treatment. Do not routinely prescribe nonsteroidal anti-inflammatory drugs.
Clarification / Additional information
  • Venous disease and venous leg ulcers are frequently painful. The pain experienced may be constant or intermittent. Severe or worsening pain may indicate a complication:
    • Constant pain can originate from vascular structures (superficial, deep phlebitis), pitting oedema, collagen (lipodermatosclerosis), or infection.
    • Intermittent pain can be related to dressing changes or debridement procedures.
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, 2006], 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.
  • Between 17% and 65% of people with a leg ulcer experience severe or continuous pain with a major impact on quality of life [Briggs and Nelson, 2003]. Pain relief is important to maximize quality of life, enable mobilization, and improve appetite.
  • CKS does not recommend nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control because they impair wound healing and may worsen leg oedema. NSAIDs affect the inflammatory phase by inhibiting cyclo-oxygenase production, which reduces the tensile strength of the wound [Enoch et al, 2006].
  • There is less evidence for the use of topical analgesic treatments in venous ulcer management [Briggs and Nelson, 2003].

How do I manage a person after their venous leg ulcer has healed?

  • Educating and encouraging the individual to adopt a lifestyle to prevent ulcer recurrence is vital. The advice should be personalized, repeated on a regular basis.
  • Explain the importance of:
    • Wearing the appropriate grade and type of compression stockings, ideally for a minimum of 5 years (although life long usage is preferable).
    • Putting compression stockings on first thing in the morning before getting out of bed.
    • Adhering to lifestyle measures.
  • Encourage the person to attend a healthy leg club — for more information, see the website www.legclub.org.
  • Follow up the person on a regular basis (every 6–12 months) to identify risk factors that may result in further skin breakdown and ulceration, such as poor skin care, worsening leg oedema, varicose veins, and leg trauma.
  • Ideally, Doppler studies should be carried out every 6 months, or sooner if clinically indicated. However, in practice the frequency of Doppler assessment will be guided by local availability and resources.
Clarification / Additional information
  • Class III (high) compression stockings should be advocated for most people but, if not tolerated, class II (medium) stockings may be considered.
  • Graduated compression stockings should ideally be used for at least 5 years after ulcer healing. Lifelong use of compression stockings may be considered in people with recurrent venous ulcers, if acceptable to the person.
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], 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.
  • The SIGN guideline highlights that chronic leg ulcers almost always recur unless measures to prevent ulcer recurrence are implemented, and it recommends the use of below-knee graduated compression hosiery where leg ulcer healing has been achieved. It recommends that compression will be required indefinitely [SIGN, 2010].
  • Twelve-month recurrence rates vary widely between different studies, from 26–69% [Nelson et al, 2000].
  • Stockings: the RCN guideline reviewed the evidence which included one systemic review (two randomized controlled trials [RCTs]) comparing different types of stockings (socks, stockings, or tights), and a subsequent RCT (n = 153) comparing class III stockings with no stockings. The subsequent RCT showed that class III stockings significantly reduce ulcer recurrence at 6 months, compared with no stockings. In the systematic review one RCT showed class III stockings to be more effective than class II stockings, although they were less well tolerated. The second RCT in the review showed no difference between two types of UK class II stockings in recurrence rates. However, wearing no stockings was associated with a higher recurrence of ulcers [Nelson et al, 2000; RCN, 2006; Rajendran et al, 2007].
  • Leg clubs: the SIGN guideline recommends leg clubs that offer support to people with venous leg ulcers, and can improve compliance with treatment regimes for some people [SIGN, 2010].

What should I do if the ulcer does not heal?

  • Refer to secondary care a person with a non-healing venous leg ulcer (if there are no signs of improvement after 2–3 months of standard care) to exclude other causes of ulceration and complications.
  • Review the person's compliance with compression therapy and lifestyle strategies and determine whether they have ongoing risk factors for venous leg ulceration.
  • After assessment by a specialist and the exclusion of alternative causes of ulceration, aim to optimize the person's quality of life (as healing of the ulcer may not be an achievable outcome despite optimal management) by controlling symptoms, encouraging mobility, and providing long-term psychological support (if needed).
Clarification / Additional information
  • Some people may benefit from seeing a specialist, as venous surgery or other medical treatment options may be considered.
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, 2006], together with informed expert opinion, and current good clinical practice [Grey et al, 2006a].

Are there any other drug treatments available?

  • Oral pentoxifylline should only be used after seeking specialist advice.
    • Pentoxifylline has been shown to reduce the healing time of venous leg ulcers [Enoch et al, 2006]. One systematic review of 12 randomized controlled trials (n = 864) suggests that pentoxifylline is more effective than placebo in reducing time to complete healing or significant improvement. Pentoxifylline plus compression is more effective than placebo plus compression, and pentoxifylline in the absence of compression appears to be more effective than placebo or no treatment.
  • There is no evidence that other drugs such as aspirin, oral zinc sulfate, or oxerutins increase the healing time of venous leg ulcers [NHS CRD, 1997; Simon et al, 2004; RCN, 2006; SIGN, 2010].

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