• Scenario: Uncomplicated venous leg ulcer: covers the management of uncomplicated venous leg ulcers.
• Scenario: Infected venous leg ulcer: covers the management of infected venous leg ulcers.
• Scenario: Healed venous leg ulcer: covers the management of healed venous leg ulcers.
• Scenario: Persistent venous leg ulcer: covers the management of unhealed venous leg ulcers.

• 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 uncomplicated venous leg ulcers involves:
• Cleaning the ulcer,
• Dressing the ulcer,
• Apply compression therapy,
• Following up and providing life-style advice.

• 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

• 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.

In depth

• 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.

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

• 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

• 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.

In depth

• 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

• 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).

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