Synopsis
Classify a chronic ulcer by perfusion, venous pressure, sensation and malignant features, choose stepwise vascular and tissue investigations, and route compression, revascularisation, offloading, infection or cancer care safely.
- Most leg ulcers are not diagnosed from the wound bed alone: location, edge, surrounding skin, pulses, capillary refill, oedema, sensation, footwear and walking history define mechanism.
- Venous ulcers are usually shallow, irregular and exudative in the gaiter area with oedema, varicosities, haemosiderin, eczema or lipodermatosclerosis.
- Arterial ulcers favour toes, heel or lateral malleolus and are punched out, painful and cool with weak pulses, delayed refill, dependent rubor or gangrene.
- Neuropathic ulcers occur at repetitive pressure points beneath callus and may be painless despite depth; a warm pulseless or pulse-present diabetic foot can still have infection, ischaemia or Charcot disease.
- Malignant ulceration is suggested by an enlarging indurated, rolled or everted edge, exuberant tissue, unexpected bleeding, pain, odour or failure to improve after the presumed cause is treated.
- First-line vascular testing is pulse examination plus Doppler pressure assessment; ABPI can be falsely high in diabetes or CKD, so toe pressure, waveforms or vascular imaging may be required.
- First-line venous-ulcer treatment is therapeutic compression only after arterial sufficiency is established; significant ischaemia needs vascular review rather than stronger bandaging.
- First-line neuropathic management is pressure removal with multidisciplinary diabetic-foot assessment, not repeated dressings while the patient continues loading the same site.
- Biopsy a suspicious viable edge and base with enough depth and communicate anticoagulation, vascular status and tumour concern; never repeatedly cauterise unexplained granulation.
Key red flags
Rest pain, tissue coldness, absent pulses, gangrene, rapidly spreading erythema, systemic illness, crepitus, exposed bone, suspected Charcot change, major bleeding, everted induration, exuberant growth or a changing scar ulcer requires expedited specialist assessment.
A sharply punched-out toe, heel or malleolar defect with cool shiny skin, delayed refill, weak pulses and rest pain indicates poor inflow.
New warmth, swelling, pain despite neuropathy, purulence, spreading erythema, systemic illness or metabolic deterioration suggests infection and may mask deep bone involvement.
Investigation priorities
Classify urgency, mechanism and baseline healing trajectory.
Management branches
Any lower-limb or foot ulcer is newly assessed or has stopped healing.
- Identify acute ischaemia, wet gangrene, sepsis, hot swollen diabetic foot and uncontrolled bleeding first and activate the corresponding emergency route.
- Examine pulses, refill, temperature, oedema, venous change, sensation and deformity and document a cleaned wound's site, edge, base and depth.
- Obtain Doppler waveforms and pressure assessment, using toe tests or vascular imaging when ABPI is unreliable or symptoms and the number disagree.
Gaiter ulceration and venous hypertension predominate without limb-threatening arterial disease.
- Use a trained clinician to apply evidence-based therapeutic compression after arterial assessment, matching system and strength to perfusion, limb shape, exudate, dexterity and tolerance.
- Treat venous eczema with emollient and a short site-appropriate topical corticosteroid and use a simple non-adherent absorbent dressing rather than an expensive product without a specific purpose.
- Refer for venous duplex and treatment of superficial reflux and address mobility, calf pump, weight and recurrence prevention with long-term compression after healing.