GPAtlas🧭 When to suspect
Suspect a venous leg ulcer in an open lesion below the knee that has not healed within 2 weeks.
• Typical site: the gaiter area (between calf and ankle, classically over the medial malleolus).
• Venous disease accounts for the majority of leg ulcers.
• Mechanism: chronic venous insufficiency → sustained venous hypertension → progressive skin breakdown.
The patient usually has a background of varicose veins, previous DVT or leg oedema, and describes an aching, heavy leg that is relieved by elevation.
Surrounding skin shows the stigmata of venous hypertension:
• Haemosiderin staining
• Varicose (venous) eczema
• Lipodermatosclerosis (the hardened, "inverted champagne bottle" lower leg)
Two clinical skills matter most:
• Confirm the ulcer is venous and exclude arterial disease (by pattern recognition and a measured ankle-brachial pressure index [ABPI])
• Treat the underlying venous cause, not just the wound
Most ulcers are colonised but not infected, and antibiotics do not promote healing of an uninfected ulcer.
| Venous ulcer | Arterial ulcer | Neuropathic ulcer |
|---|---|---|
|
• Site: gaiter area, medial malleolus • Look: shallow, irregular, sloughy/granulating, exudative • Pain: aching/heavy, eased by elevation • Skin: haemosiderin, venous eczema, lipodermatosclerosis, oedema |
• Site: toes, heel, lateral malleolus, pressure points • Look: "punched-out", deep, dry, pale/necrotic base • Pain: severe, worse on elevation and at night • Skin: cold, shiny, hairless; pulses reduced/absent |
• Site: sole, under metatarsal heads, pressure points • Look: deep, surrounded by callus; may probe to bone • Pain: often painless (neuropathy) • Skin: warm, dry; pulses usually intact; often diabetic |
Risk factors strengthening suspicion:
• A previous leg ulcer (the strongest predictor of recurrence)
• Varicose veins
• Prior DVT or phlebitis
• Obesity
• Immobility
• Increasing age
• Comorbidities such as diabetes or peripheral arterial disease (which raise the chance of a mixed or arterial ulcer)
Source: NWCSP · NICE NG152
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