Leg ulcers

The following information about leg ulcers is taken from 3D Regional HealthPathways, accessed June 2020:

Background

About leg ulcers

Leg ulcers are wounds on the lower limb that have been present for 2 weeks. The most common causes of leg ulceration seen in general practice are:

• Venous insufficiency (most common)
• Arterial ulcers are less common and require revascularisation
• Mixed aetiology (arterial and venous)
• Atypical or other:
      ◊ Malignant causes
      ◊ Pressure ulcers
      ◊ Pyogenic granuloma
      ◊ Bullous pemphigoid
      ◊ Iatrogenic or trauma (e.g., skin tears)
      ◊ Vasculitic ulcers
      ◊ Auto-immune causes

The management of leg ulcers is complex. The simple rule is to treat the whole patient and not the hole in the patient.

All patients with non-healing wounds that have been present for 2 weeks on the lower limb require specialist assessment to ensure appropriate management.

Assessment

1. Assess and manage the wound according to the General Wound Care pathway.
2. If there is inadequate healing or failure to reduce in size within 2 weeks, look for the underlying cause, or causes, of the ulceration:
     • Diabetic foot ulcers
     • Chronic venous insufficiency
     • Peripheral vascular disease
     • Lymphoedema
     • Malignancy
3. Consider other factors that may affect healing.

Management

Diabetic neuropathic ulceration

1. If the wound is a diabetic neuropathic wound, see Diabetes Foot Care.
2. Advise the patient not to weight bear – arrange use of wheelchair or crutches for offloading.

Venous leg ulcers

1. Request specialised wound care nursing for compression therapy.
2. Venous eczema is common. Regular emollients are important with short courses of moderately potent steroids for flare ups.
3. If there are symptoms or signs of localised, spreading or systemic infection:
      • Swabs are of limited use and cannot determine whether an ulcer is infected or not.
      • Systemic antibiotics are generally only useful if there is clinical evidence of spreading or systemic infection. Topical antibiotics are not recommended.
      • See also Wound Infections.
4. If there are recurrent ulcers despite adequate compression therapy, request non-acute vascular surgery assessment.

Arterial leg ulcers

1. Request assessment for revascularisation where possible:
      • If there are clinical signs of critical limb ischaemia (rest pain and/or tissue loss with absent pulses), request acute vascular surgery assessment.
      • If there are signs of peripheral vascular disease other than critical limb ischaemia, request non-acute vascular surgery assessment and specialised wound care nursing assessment (for wound assessment, care and monitoring), at the same time.
2. Provide adequate analgesia. Pain may be severe and short term opiates are often required. See Analgesia in Adults with Acute Pain.
3. If the wound is dry, ensure it is kept dry to prevent secondary infection. Paint with betadine and apply padded dry dressing. If the patient is allergic to iodine, use nothing but a dry dressing.
4. If pulses are palpable, it is safe to use a single layer Tubigrip bandage to help control oedema.

Lymphatic leg ulcers

1. Request specialised wound care nursing assessment for compression therapy.
2. See the Lymphoedema pathway.

Suspected Malignant ulcers

1. If malignancy is suspected in any non-healing or atypical leg ulcer, consider biopsy.
2. Suspected or biopsy-proven malignant ulcers require surgical excision. Request non-acute plastic surgery assessment if access criteria are met.

Learn more

Australian and New Zealand Clinical Practice Guideline for prevention and management of venous leg ulcers Australian Wound Management Association and New Zealand Wound Care Society

References

1. Leg ulcers 3D Regional HealthPathways, NZ, 2020