LEG ULCERS

2ND YEAR TEACHING

2013
Dr Bryden
Consultant Dermatologist
Ninewells Hospital
Dundee

any break in the skin

of the lower leg above the
ankle

present more than 4

BACKGROUND
60-80% of leg ulcers are venous in nature
Lothian and Forth Valley study:

76% venous disease

22% arterial disease
9% rheumatoid arthritis
5% diabetic
Mixed arterial venous disease 10-20%

HOW COMMON ARE LEG

ULCERS?
UK prevalence 0.1 0.3% (62-186,000))
Approx 1% of population will have a leg ulcer

at some point in their lives (620,000 UK)

Prevalence increases with age
Ageing population therefore problem is going

to increase

HOW COMMON ARE LEG

ULCERS?
Local population

Predicted leg ulcers

Tayside 392,000

1,176

(65+, 38,600)
Dundee 142,000

(65+13,300)
Angus 110,000
(65+, 11,100)
Perth and Kinross
140,000 (65+,14,200)
?North-East Fife

426
330
420
NHS tayside gender equality population profile 2007

WHO TREATS?
>80% of chronic venous leg ulcers cared for

in the community
12% joint effort community and secondary

care (secondary care specialists can be

Dermatologists, Vascular Surgeons, Plastic
surgeons, Tissue viability teams etc.)
5% in patient treatment (2002 figures)

WHY ARE LEG ULCERS IMPORTANT

Morbidity pain, sepsis, exudate, odour etc
Impaired quality of life
Financial cost (UK)
Approx 1500 per annum to treat 1 leg ulcer
(2001 prices)
1 billion pounds per annum (chronic wounds)

Venous

Arterial (or mixed arterio-venous)

Diabetic

Vasculitic

Malignant

Hydrostatic - dependant limb

NB all ulcers multifactorial

History duration of present ulcer. Is this

their first ulcer?

Pain; disturbing sleep; affecting mobility

Medical history especially ask about h/o

varicose veins, DVT, clotting problems,

peripheral vascular disease, arterial disease
elsewhere, diabetes.

Record the following details:

position of ulcer
measure surface area

Lipodermatosclerosis
Hyperpigmentation
Malleolus

Venous ulcer

SLOUGH

ABPI (ankle/ brachial

pressure index)
0.8-1.3 normal
< 0.8 - vascular

disease
>1.5 calcification

30 minute procedure

ABPI

Differentiate venous from

arterial and mixed ulcers

Wound swab

- ONLY

If ulcer increasingly
painful/exudative/smelly/
enlarging

Bloods

- FBC, LFTs, U+Es, CRP

Patch testing
- To previous ulcer

treatments eg. Bandages,

dressings, creams

Duplex scan if

indicated

Control pain
ABPI
Non-adherent dressing
De-sloughing agent if necessary eg hydrogel/ honey
4 layer compression bandaging may need to

increase compression gradually if pain a problem

Leg elevation

Graduated compression
40mmHg at ankle, 25mmHg below knee
Latex/ rubber free if possible
Applied by a trained nurse
Non-adherent dressing
Leg padded to a cone shape
Changed weekly, or as required

AIM TO HEAL ULCERS BY 12 WEEKS

Dressings seldom heal wounds on their own:

simple non-adherent dressings
absorption: hydrocolloids eg aquacel
antibacterial: silver/ iodine or manuka honey

60% recurrence
rate at 1 year if
no prevention
Class 1(weak)
to class 3
(strong).
Most patients
manage class 2
stockings

SIGN 120
1)All patients with chronic venous leg ulcer

should have an ABPI performed prior to

treatment
2)Measurement of ABPI should be performed
by appropriately trained practitioners who
should endeavour to maintain their skills
3)Compression should only be applied by staff
with appropriate training

The future..
Scale of current problem huge
Is going to get worse
Guidelines not being followed
Patients suffering an unpleasant, painful and

life-altering condition for far longer than they

need to
Huge cost savings to be made if duration of
ulcer reduced and prevention of recurrence
addressed

VENOUS ULCER

VENOUS DERMATITIS

ATROPHIE BLANCHE

ABPI = 0.9

ABPI = 0.6

Arterial ulcer

BASAL CELL CARCINOMA

Make a diagnosis
ABPI
SIGN 120
Trained staff to apply compression
Re-assess if not improving
For difficult wounds consider other treatments/

referral to secondary care

Aim to heal simple venous ulcers by 12 weeks

Thank you for listening!

LEG ULCER QUIZ

QUESTION 1

Is this ulcer:

a)
b)
c)
d)

Arterial
Diabetic
Venous
Traumatic

QUESTION 2

Which of the following is a normal ABPI?

a)
b)
c)
d)

0.9
1.6
0.3
2.2

QUESTION 3

The term for woody tethered skin

affecting the lower leg is:

a)
b)
c)
d)

Varicosity
Dermatitis
Atrophie blanche
Lipodermatosclerosis

QUESTION 4

Which of the following dressings heal ulcers?

a)Aquacel AG
b)Non-adherent dressings
c)Both of the above
d)None of the above

QUESTION 5

Is this ulcer:
a)
b)
c)
d)

Diabetic
Venous
Arterial
Neuropathic

QUESTION 6
What is slough?
a)Healthy skin
b)Active infection
c)Skin debris and dead bacteria
d)Granulation tissue

QUESTION 7
How can slough be
removed?
a)Compression bandaging
b)Hydrogels
c)Manual debridement
d)All of the above

QUESTION 8
Which ulcers should be
swabbed?
a)All ulcers
b)Sloughy ulcers
c)Painful ulcers
d)Only those showing signs of
clinical infection

QUESTION 9
How should a leg ulcer be cleaned?
a)
b)
c)
d)

Warm tap water and soap substitute

Sterile saline solution
Hibiscrub
They shouldnt be washed

QUESTION 10

How should venous dermatitis be managed?

a)
b)
c)
d)
e)

Apply regular emollients

Consider patch testing
Topical steroids
Compression bandages or stockings
All of the above

QUESTION 11

Which of the following could be the cause of a non-healing

leg ulcer?
a)
b)
c)
d)

Skin cancer
Inflammatory skin disease
Poor hygiene
a and b

QUESTION 12
Which of these conditions are important in the
management of leg ulcers?
a)
b)
c)
d)

Cardiovascular disease
Diabetes
Deep venous thrombosis
All of the above

QUESTION 13
Which of these is a common site for venous ulcers
a)
b)
c)
d)

Heel
Medial and lateral malleoli
Shin
calf

QUESTION 14

Why is ABPI performed?

a)
b)
c)
d)

To
To
To
To

check for DVT

examine the varicose veins prior to surgery
assess the arterial system
measure oxygen levels in the feet

QUESTION 15
What shape are you aiming for when padding and shaping
a leg prior to bandaging?
a)
b)
c)
d)

Oval
Rectangle
Cone
Triangle

QUESTION 16
What is the most important therapy in healing leg ulcers?
a)
b)
c)
d)

Dressings
Antibiotics
Skin grafts
Compression

QUESTION 17
Once a venous ulcer is healed, what should the patient be
advised to do?
a)
b)
c)
d)

Nothing
Use regular emollient
Wear appropriate strength compression stockings
b and c

QUESTION 18
How long do compression stockings last?
a)
b)
c)
d)

4-6 months
Forever
2 months
12 months

QUESTION 19
What does SIGN stand for?
a)
b)
c)
d)

Scottish interventional group of nurses

Standards of investigation network
Scottish inter-collegiate guidelines network
Somebody issues guidelines network

QUESTION 20
What is this dressing?
a)
b)
c)
d)

Aquacel
Mepilex
Maggots
Lyofoam

WELL DONE