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Venous leg ulcer
A venous ulcer is the commonest leg ulcer — shallow, irregular and exudative, above the medial malleolus, on a background of pigmentation and hard skin; the basis of treatment is compression bandaging after ABI has been checked, plus early ablation of the superficial veins, which speeds healing and reduces recurrence; an ulcer that does not heal or looks atypical requires biopsy.
Why it matters in the exam
The exam asks to distinguish venous, arterial and neuropathic ulcers. A venous ulcer lies in the "gaiter" area above the medial malleolus, is shallow, with irregular edges and heavy exudate, moderate pain that improves with leg elevation, and around it brown pigmentation, eczema and hardened skin (lipodermatosclerosis). An arterial ulcer, in contrast, lies at the toe tips or over bony prominences, is deep and "punched out", with a pale base and pain that worsens with elevation; a neuropathic ulcer lies at pressure points of the foot. Before compression ABI must be measured, because many older patients also have arterial disease: an ABI of 0.8 or more allows full compression (about 40 mmHg); ABI between 0.5 and 0.8 — reduced compression under supervision, and referral for vascular assessment; ABI below 0.5 — no compression, and urgent referral to a vascular surgeon.
Treatment: multilayer compression bandaging, leg elevation, movement (calf muscle pump), local wound care and care of the surrounding skin. The EVRA trial (2018) showed that superficial venous ablation within 2 weeks of diagnosis, in addition to compression, shortens healing time and lengthens ulcer-free time, so every patient with a venous ulcer needs duplex and assessment for ablation. Antibiotics are given only for clinical infection (cellulitis), not because of a positive surface swab. Pentoxifylline or flavonoid preparations can be used as adjuncts. An ulcer that does not heal after about 6 weeks of correct treatment, or looks atypical (raised edges, excessive granulation tissue), needs biopsy to exclude cancer — for example squamous cell carcinoma in a chronic ulcer (Marjolin). After healing, long-term compression stockings and treatment of reflux reduce recurrence. In selected patients with deep venous obstruction in the pelvis (for example after thrombosis) a venous stent can help.
Non-venous causes of leg ulcer — vasculitis, pyoderma gangrenosum, blood disorders and infections — must also be considered when the picture is atypical.
Key points
- Above the medial malleolus, shallow and exudative.
- ABI before compression.
- Multilayer compression bandaging.
- EVRA — ablation within 2 weeks.
- Not healed after about 6 weeks — biopsy.
Summary table
| Feature | Venous ulcer | Arterial ulcer |
|---|---|---|
| Location | Above the medial malleolus | Toe tips, bony prominences |
| Appearance | Shallow, irregular, exudative | Deep, "punched out", pale base |
| Pain | Moderate, improves with elevation | Severe, worsens with elevation |
| Surrounding skin | Pigmentation, lipodermatosclerosis | Thin shiny skin, hairless |
| Treatment | Compression and early ablation | Revascularisation; no compression |
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Sources
- ESVS Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs, 2022 — Venous leg ulcer
- SVS/AVF Clinical Practice Guidelines: Management of venous leg ulcers, 2014 — Recommendations
- Gohel et al., EVRA, N Engl J Med, 2018 — Early endovenous ablation in venous ulceration
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.