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.
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.
Investigation priorities
Measure arterial perfusion before therapeutic compression and support PAD diagnosis.
Management branches
Venous phenotype and ABPI 0.8–1.3 with no acute arterial red flags.
- First: clean, choose a simple low-adherence absorbent dressing, moisturise surrounding skin and address pain/mobility.
- Next: apply strong multicomponent compression targeting about 40 mmHg at the ankle by a trained practitioner.
Key medicines
Flucloxacillin500 mg–1 g orally four times daily for 7 days.
Doxycycline200 mg orally on day 1, then 100 mg once daily to complete 7 days (200 mg daily may be used for severe infection under NICE guidance).