What are leg ulcers?

A leg ulcer is an area of the leg where the skin has broken down and is slow to heal. It is a common condition in our population, and we are seeing it more frequently in the elderly.

What causes leg ulcers?

The main causes of leg ulcers include:

  1. Arterial leg ulcers – a lack of circulation leads to skin breakdown and ulcers. These ulcers are often painful and can lead to gangrene and amputation if left untreated.
  2. Venous leg ulcers – increased pressure in the veins over a long period of time can lead to leg ulcers e.g. untreated varicose veins.
  3. Diabetic foot ulcers – people with diabetes are at a much higher risk of developing foot ulcers for a variety of reasons which include poor circulation, as well as an increased risk of infection.
  4. Other causes – these can be vasculitic ulcers (where the person’s own immune system attacks the skin and causes it to break down) and skin cancer ulcers.

Often, the ulcer is caused by a combination of the above reasons.

The correct diagnosis of the ulcer is critical in order for treatment and healing to occur. Each of the above causes of leg ulcers requires different treatment options. Fortunately, with evolving technology, most of the treatments now include minimally invasive (key-hole) methods not requiring surgery or a general anaesthetic.  This includes angioplasty and stenting for arterial ulcers and laser treatment for varicose veins.

Dr Shakibaie has a special interest in the management of leg ulcers and has a wealth of experience in managing the conditions which lead to leg ulcers with minimally invasive means. He has often managed to heal a long-term ulcer and save the leg with angioplasty and stenting when other vascular surgeons have recommended major surgery.

It is important to not only heal the ulcer, but also to prevent a recurrence of any leg ulcers. Dr Shakibaie will give advice and arrange any follow-up required to achieve this. Leg ulcers are a condition where prevention really is better than treatment.

Causes of leg ulcers

Leg ulcers can be caused by a number of different disease processes or conditions. Commonly, leg ulcers can occur due to issues with arteries or veins in the legs, or as a complication of diabetes.

Signs and symptoms

Leg ulcers, of any cause, occur where the skin breaks down. They are moist, shallow wounds

Venous ulcers

The most common type of leg ulcers are venous ulcers. If the valves are not working properly in the veins in your legs this can lead to increased pressure, and cause venous ulcers to develop.

Risk factors for developing venous ulcers include:

  • Varicose veins
  • Family history
  • Obesity
  • Deep vein thrombosis
  • Prior leg fracture
  • Poor calf muscle function

The doctor can make a diagnosis of venous ulcers following a clinical examination, which can be confirmed by duplex ultrasound.

Arterial ulcers

If there is reduced blood flow to the legs this may result in ulcers. In particular, peripheral arterial disease can cause reduced blood flow through the arteries to the legs causing ulcers. Ulcers of this type usually appear on the toes or on areas where they are under more pressure including the heels, ankles and shins.

Risk factors for peripheral arterial disease include:

  • Diabetes
  • Obesity
  • High blood pressure
  • Smoking
  • High cholesterol

Neuropathic causes of leg ulcers

A neuropathy is a condition affecting the nerves. Diabetes is the major neuropathic cause of leg ulcers. People with diabetes have a 25% risk of developing foot ulcers over their lifetime. Diabetic foot ulcers are usually painless and occur in areas of increased pressure.

Risk factors for patients with diabetes developing ulcers include:

  • Sensory neuropathy
  • Charcot’s mid-foot deformity
  • Chronic kidney disease
  • Previous history of foot ulcer or amputation

Examination and investigations

Questions the doctor may ask

Before examining your legs for ulcers, the doctor will ask you some questions to understand how long the ulcers have been there as well as if you have had ulcers before. They will also ask questions about your symptoms and any other conditions that you may have. This will help to give the doctor some information about the possible underlying cause of the ulcers.

Examining the ulcers

When examining for ulcers the doctor will look closely at the appearance of your skin, feel for pulses at different locations and check the mobility of both of your legs.

They might also perform investigations to aid in their diagnosis of the underlying cause of the ulcers. The doctor may use the ankle-brachial index, which is the ratio of the blood pressure at the ankle compared to the pressure in the arm.

The doctor may also utilise duplex ultrasound which would help visualise any issues in the blood vessels.

The correct treatment for leg ulcers is dependent on the correct diagnosis of the underlying cause. As discussed, the most common causes of leg ulcers are venous insufficiency, arterial insufficiency and neuropathic diseases such as diabetes.

Treating venous ulcers

Initially, compression therapy is often recommended as the first line of treatment for acute venous ulcers. This involves either applying a graduated compression bandage (one with two to four layers) to the area or wearing special stockings. This supports the valves in your legs, and can help with circulation problems. Compression therapy should only be started by a healthcare professional. For chronic ulcers that have persisted for long periods of time, surgical evaluation should be considered. The role of surgery in treating venous ulcers can involve addressing the underlying venous insufficiency. This can help prevent the reoccurrence of ulcers in the future.  As such, the methods used are similar to those used in treating varicose veins and include sclerotherapy and laser therapy.

Laser therapy is minimally invasive and uses ultrasound to guide a tube (also known as a catheter) into the vein. When the tube is correctly placed in the vein, laser energy is used to heat the tip of the tube. This heat then causes the vein to collapse.

This procedure can be performed in Dr Shakibaie’s office and only requires a local anaesthetic. After the procedure patients can normally return to their usual daily activities within 24-72 hours, provided they follow the correct after treatment care.

Treating arterial ulcers

Angioplasty and stenting are common procedures used to treat arterial ulcers. During an angioplasty procedure, a needle is inserted into the artery and a dye is injected, to show the blood flowing through the arteries and make it easier to see the blocked area. A small tube with a balloon is inserted into the artery to the blocked area and the balloon is then inflated. This unblocks the artery. Sometimes a stent may also be left in the blocked area which keeps the artery open and allows blood to flow through.

Angioplasty and stenting is usually performed under a local anaesthetic and in most cases patients can go home the same day or the next day after the procedure.

After receiving treatment for leg ulcers there are a number of things you need to do to make sure that your treatment is as effective as possible and your recovery is as smooth as possible.

The treatment you receive for your leg ulcers will vary depending on what has caused the ulcers. Different treatments require different care after treatment. For example, the steps that you need to take after laser therapy are different to if you were treated using angioplasty. It is important to carefully read through the instructions for your specific treatment, and if you have any questions or concerns please do not hesitate to contact Dr Shakibaie’s office.