Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
Venous, arterial, neuropathic and malignant ulcers
Essential points for quick revision.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Threatened limb, spreading infection or haemorrhage
Sudden severe pain, pallor, pulselessness, paraesthesia, paralysis or coldness indicates acute limb ischaemia; rapidly spreading infection, crepitus, systemic toxicity, wet gangrene, uncontrolled tumour bleeding or a hot swollen diabetic foot can destroy tissue or life quickly.
Action: Arrange immediate vascular, surgical or diabetic-foot admission as appropriate, keep an ischaemic limb dependent and uncompressed, begin sepsis and antimicrobial care when indicated, and control bleeding with non-adherent pressure while urgent cancer or interventional support is mobilised.
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.
A sharply punched-out toe, heel or malleolar defect with cool shiny skin, delayed refill, weak pulses and rest pain indicates poor inflow.
Investigation priorities
01
Complete limb and wound assessmentFirst step
Classify urgency, mechanism and baseline healing trajectory.
Management branches
First classification sequenceCheck blood flow before choosing a dressing pathway
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.
First-line venous routeCompress only an adequately perfused limb
Gaiter ulceration and venous hypertension predominate without limb-threatening arterial disease.
Key medicines
Flucloxacillin for infected leg ulcerTake 500 mg to 1 g by mouth four times daily for 7 days when a leg ulcer has clinical bacterial infection and oral treatment is appropriate, following local antimicrobial guidance.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.