• 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 and venous eczema.
• Look for signs of an infected leg ulcer such as:
• Enlarging ulcer.
• Increased exudate or 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 granulation, and fibrous or necrotic tissue which may need to be removed to allow healing. 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.

In depth

• 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 a 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.

In depth

• Managing infected venous leg ulcers involves:
• Cleaning the ulcer,
• Dressing the ulcer,
• Taking a wound swab and prescribing an antibiotic,
• Following up and,
• Giving life-style advice.

• Signs of an infected venous leg ulcer include:
• Enlarging ulcer.
• Increased exudate.
• Increased pain.
• Pyrexia.
• Foul odour.
• Cellulitis: surrounding skin is red, hot and non-scaling.

• Irrigate the ulcer at each dressing change with warm tap water or saline, then dry (strict aseptic technique is not required).
• Remove slough, necrotic, fibrous, or excess granulation tissue by gentle washing.
• Debridement is not usually necessary. 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.

In depth

• 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.

In depth

• 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.

In depth

• 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.

In depth

• 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.

In depth

• 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.

In depth

• 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.

In depth

• 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.

In depth