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Dermatology (Skin Conditions)

Leg Ulcers (Approach)

Approach to chronic ulcerative lesions on the lower leg, requiring assessment to determine the underlying cause (most commonly vascular) and appropriate management.

Also known as: Chronic Leg Wound

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Referral and warning signs

When to refer

Refer to Specialist (Vascular Surgeon, Dermatologist, Wound Care Specialist, Diabetologist) if: Arterial ulcer (ABPI <0.8). Neuropathic ulcer (needs offloading/specialist foot care). Venous ulcer not improving with compression after 4-6 weeks. Suspected malignancy or vasculitis (needs biopsy). Signs of deep infection (osteomyelitis). Need for advanced therapies or debridement.

Red flags

  • Signs of critical limb ischaemia (rest pain, cold pale foot, absent pulses).
  • Rapidly expanding ulcer or surrounding cellulitis.
  • Signs of systemic sepsis.
  • Suspicious features for malignancy (rolled edge, persistent bleeding, rapid growth).
  • Exposure of bone or tendon.
  • Severe, uncontrolled pain.

Signs and symptoms

  • Open sore/wound on the lower leg (often ankle area) that fails to heal within expected timeframe (e.g., >4-6 weeks).
  • Pain (variable - venous often less painful than arterial/neuropathic unless infected).
  • Exudate (discharge - serous, purulent, bloody).
  • Malodour.
  • Surrounding skin changes:
  • - Venous Ulcer: Gaiter area (medial malleolus common), irregular shape, shallow, sloping edges, surrounding stasis dermatitis (eczema, pigmentation, lipodermatosclerosis - hardening), oedema.
  • - Arterial Ulcer: Pressure points (toes, heels, lateral malleolus), 'punched-out' appearance, well-defined edges, pale/necrotic base, surrounding skin cool, pale, hairless, shiny; associated claudication pain, weak/absent pulses.
  • - Neuropathic (Diabetic) Ulcer: Pressure points on sole of foot (metatarsal heads, heel), often deep, surrounded by callus, painless (due to neuropathy), warm foot with palpable pulses usually.
  • - Other Causes: May have features of underlying condition (e.g., vasculitis, infection, malignancy).

Risk factors

  • Venous: Chronic venous insufficiency (previous DVT, varicose veins, obesity, immobility, heart failure).
  • Arterial: Peripheral arterial disease (smoking, diabetes, hypertension, dyslipidemia, older age).
  • Neuropathic: Diabetes Mellitus (peripheral neuropathy), Leprosy, Spinal cord injury.
  • Other: Trauma, Infection (Buruli ulcer, TB, fungal), Vasculitis, Malignancy (SCC, BCC, melanoma), Sickle Cell Disease, Pyoderma gangrenosum, Pressure injury.

Diagnosis

Clinical assessment

History (duration, pain, previous ulcers, risk factors - DVT, PAD, diabetes, smoking). Examination: Location, size, shape, edge, base, surrounding skin, oedema, pulses (dorsalis pedis, posterior tibial), ankle-brachial pressure index (ABPI - arterial), sensation (neuropathy).

Differential diagnosis

  • Differentiate between Venous, Arterial, Neuropathic ulcers.
  • Rule out Infection (Buruli, TB), Malignancy, Vasculitis, Sickle Cell ulcer, Pyoderma Gangrenosum, Ecthyma.

Investigations

  • Wound Swab for Culture & Sensitivity (if infection suspected).
  • Ankle-Brachial Pressure Index (ABPI): Assess arterial supply (Normal 0.9-1.3; <0.9 suggests PAD; >1.3 suggests calcified vessels).
  • Blood Glucose / HbA1c (rule out/assess diabetes).
  • Full Blood Count (FBC).
  • Biopsy of ulcer edge/base: If malignancy suspected, atypical appearance, or non-healing despite appropriate care.
  • Duplex Ultrasound (Vascular): Assess venous reflux or arterial stenosis.
  • X-ray: If underlying osteomyelitis suspected.

Diagnostic criteria

Clinical assessment + ABPI helps differentiate vascular causes. Biopsy confirms malignancy/vasculitis/specific infections.

Management

Non-pharmacological management

  • Treat Underlying Cause:
  • - Venous: Compression Therapy (multi-layer bandaging or stockings) is KEY - *only if ABPI >0.8*. Leg elevation.
  • - Arterial: Vascular surgery referral for revascularization. AVOID compression.
  • - Neuropathic: Offloading pressure (specialized footwear, casting), foot care.
  • - Treat diabetes, infection, etc.
  • Local Wound Care:
  • - Debridement: Removal of necrotic tissue/slough (surgical, enzymatic, autolytic).
  • - Cleansing: Normal saline or clean water irrigation.
  • - Dressings: Choose based on wound stage, exudate level, presence of infection (e.g., hydrocolloids, foams, alginates, hydrogels). Aim for moist wound healing environment.
  • - Manage exudate.
  • - Protect surrounding skin (barrier creams).
  • General: Leg elevation (venous), Pain management, Nutritional support.

Pharmacological treatment

  • Analgesia: Paracetamol, NSAIDs (use cautiously), Neuropathic agents (if needed), Opioids.
  • Antimicrobials:
  • - Topical: Silver sulfadiazine or Povidone-iodine ONLY if wound dirty/exudative initially (UCG). Antiseptics generally discouraged long-term.
  • - Systemic Antibiotics: ONLY if clinical signs of infection present (spreading cellulitis, increased pain/exudate, fever). Treat based on likely pathogens/culture results (cover Staph/Strep +/- anaerobes/Gram-negatives). See Cellulitis (DER003).
  • Pentoxifylline: May aid venous ulcer healing (adjunct to compression).
  • Growth Factors / Skin Substitutes: Specialist use.

Monitoring

Regular assessment of wound healing (size, tissue type, exudate). Monitor surrounding skin. Assess pain. Monitor effectiveness of compression/offloading. Re-evaluate if not healing.

Complications

  • Infection (cellulitis, osteomyelitis, sepsis).
  • Pain.
  • Reduced mobility / Quality of life.
  • Delayed healing / Chronicity.
  • Malignant change (Marjolin's ulcer - SCC in chronic wound).
  • Amputation (severe arterial insufficiency or infection).

Prevention

  • Manage risk factors (venous insufficiency - compression, PAD - risk factor modification, diabetes - foot care/glucose control).
  • Protect legs from trauma.
  • Good skin care.
  • Early intervention for minor wounds in high-risk patients.

Patient education

  • Explanation of ulcer type and underlying cause.
  • Importance of treating the cause (e.g., compression for venous, offloading for neuropathic).
  • Wound care instructions (cleansing, dressings).
  • Importance of leg elevation (venous).
  • Foot care advice (diabetic).
  • Recognizing signs of infection or worsening.
  • Lifestyle changes (smoking cessation, diet, exercise).
  • Importance of adherence to compression/offloading.

Uganda-specific notes

Venous ulcers common. Need to consider infectious causes like Buruli ulcer or TB. Access to ABPI, Duplex scans, compression bandaging systems, and specialist care is limited. Focus on basic wound care, elevation, and treating infection. Diabetic foot care capacity is growing but needs strengthening.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 22, Section 22.6.1

For learning and professional reference. Use current local guidance and clinical judgement.

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