Synopsis
Differentiate venous from arterial ulceration, assess perfusion before compression and coordinate wound, vascular and infection treatment.
- Venous ulcers are usually shallow, exudative and irregular in the gaiter region with oedema, pigmentation or eczema; arterial ulcers are often distal, punched out, painful and associated with a cool pulseless foot.
- Assess both arterial perfusion and venous disease: ulcer appearance alone is not reliable, and mixed aetiology is common.
- Measure Doppler ABPI before strong compression; in diabetes/CKD, add toe pressure or waveform assessment when vessels are calcified or ABPI is high/unreliable.
- ABPI 0.8–1.3 generally permits full/strong venous compression; ABPI 0.5–0.79 needs reduced compression under specialist oversight; below 0.5 needs urgent vascular assessment and no routine compression.
- For a venous ulcer with adequate arterial inflow, strong compression delivering about 40 mmHg at the ankle is the core healing treatment, applied by a trained clinician.
- Arterial ulceration needs urgent vascular referral and revascularisation assessment; dressings and analgesia cannot restore perfusion.
- Most leg ulcers are colonised: give antibiotics only for clinical infection such as spreading redness/swelling beyond the ulcer, local warmth, increasing pain or fever.
- Refer a venous leg ulcer not healed within 2 weeks, and a healed venous ulcer, to a vascular service for duplex and treatment of superficial reflux.
Key red flags
Distal toe/foot, pressure-point or lateral malleolar lesion with a punched-out pale/necrotic base, cool shiny skin, delayed refill and reduced pulses; often painful and worse with elevation.
Pressure-site callus, altered sensation and deformity; infection and ischaemia may be painless and require the NICE diabetic-foot pathway.
Spreading erythema/swelling beyond the ulcer, warmth, increased pain, purulent discharge or fever; wet gangrene, systemic illness or deep infection is an emergency.