DermatologyTier 1Disease (DEADMAN)

Skin ulcers - venous

Description

Commonest type of chronic leg ulcer - gaiter region (medial malleolus), irregular border, shallow, exudative, associated with signs of chronic venous insufficiency

Prevalence rises with age; risk factors - obesity, prior DVT, varicose veins, immobility, multiparity, prolonged standing occupation

Venous hypertension (valvular incompetence, post-thrombotic syndrome, calf muscle pump failure) -> capillary leakage, fibrin cuff formation, chronic inflammation -> tissue hypoxia and breakdown
Associated skin changes: lipodermatosclerosis (woody induration), haemosiderin pigmentation, atrophie blanche, venous eczema

Clinical - gaiter distribution, irregular shallow ulcer, surrounding venous skin changes
Ankle-brachial pressure index (ABPI) essential before compression - excludes significant arterial disease (compression is contraindicated/dangerous if ABPI <0.8)
Venous duplex ultrasound to characterise reflux/obstruction if intervention being considered

Compression therapy (multilayer bandaging or compression stockings) is first-line once arterial disease excluded by ABPI
Leg elevation, regular ambulation/calf muscle pump exercise
Wound bed preparation - debridement of slough, appropriate moist dressing selection
Endovenous ablation of superficial venous reflux improves healing and reduces recurrence in appropriately selected patients (adjunct to, not replacement for, compression)
Treat venous eczema (topical corticosteroid) and manage lipodermatosclerosis
Long-term compression stockings after healing to prevent recurrence

Chronic, relapsing - high recurrence rate without ongoing compression therapy
Healing can take months even with optimal management
Endovenous ablation of reflux reduces recurrence but does not replace the need for compression

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