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What is a venous leg ulcer?
There are several types of ulcer affecting the lower limbs, such as venous ulcers, arterial ulcers and diabetic foot ulcers (plantar perforating disease). There are also mixed ulcers, both arterial and venous(1).
Venous ulcers (VU) are the most common leg ulcers(2). These are chronic ulcers, meaning that they have not healed for more than a month. They are located mainly on the distal part of the leg (ankle and lower leg area) and result from venous hypertension(3,4).
This venous hypertension leading to venous leg ulcers (VLU) can be caused by(1,5):
Reflux into superficial veins due to venous insufficiency,
Reflux or obstruction in the deep veins of the leg,
And/or a deficiency in the calf muscle pump (the calf muscles do not work properly to help push blood from the legs to the heart).
Venous leg ulcers (VLU) correspond to stages C5 and C6 of the CEAP classification, which assesses and describes the stages of chronic venous disease (healed ulcer (C5) and active/open ulcer (C6) respectively). Venous ulcers are therefore the most advanced stage of chronic venous disease and it is estimated that they affect 1% of the general population, 1 to 3% of the over-60s and over 3% of the over-80s in Western countries(6,7,8). In fact, the prevalence of venous ulcers increases with age(4).
Women are more likely to develop ulcers; they are 1.5 times more common, particularly after the age of 50(5).
Although venous leg ulcers are not life-threatening, they do have a serious impact on patients' quality of life(9).
What are the characteristics of venous leg ulcers?
Location Generally located on bony prominences such as the perimalleolar area, i.e. the area around the malleolus (ankle bone) or up to the lower third of the calf(1,3).
Appearance Venous ulcers are generally irregular and shallow(1). Associated signs of venous disease, such as varicose veins, oedema, venous dermatitis, skin hyperpigmentation and other skin changes may also be present(1,3,4).
Symptoms Reported symptoms often include heaviness of the limbs, itching, pain, skin discolouration and oedema which worsens throughout the day and improves with elevation(1,3). The pain caused by ulcers is often moderate but can range from minimal to severe(3,5).
Exudate Persistent secretion is seen(3). These defects may vary in size, from small ‘spots’ to large circular defects, but also in depth, ranging from superficial defects to deep tissue damage resembling a crater, or in appearance (light pink to black)(3).
What causes an ulcer?
A venous ulcer can occur after a minor injury but is mainly caused by venous hypertension, which results from venous reflux or venous obstruction. Venous reflux occurs when the venous valves, which act like flaps to prevent blood from flowing back down under the effect of gravity, fail(1,7).
These valves normally ensure the unidirectional flow of blood to the heart. When they become incompetent (for example due to damage or a lack of vessel tone), they no longer close properly, resulting in an abnormal return of blood to the lower limbs(3,10).
Venous blood then stagnates, increasing the pressure in the veins (venous hypertension). This blood is deoxygenated, accumulates under the skin and causes venous ischaemia and hypoxia, leading to the appearance of oedema, inflammation, skin changes and finally venous ulceration(1,3).
This inflammation, which affects the veins, their walls and valves, leads to a leakage of cells, metabolic waste and inflammatory substances into the surrounding tissues. These factors lead to cell death and skin breakdown, resulting in the formation of ulcers(1,3).
What are the risk factors for developing venous ulcers?
Risk factors include(1,3):
Age (55 or over)
High body mass index (BMI)
A high number of pregnancies
Physical inactivity
Smoking
Venous reflux in the deep veins
A history of injury
A family history of chronic venous insufficiency
History of pulmonary embolism or superficial/deep vein thrombosis
Parental history of ankle ulcers
A history of ulcers
Severe lipodermatosclerosis (a complication of chronic venous disease characterised by hardening and thickening of the skin and tissues around the ankles, increased pigmentation, swelling and redness).
What are the healing stages of venous leg ulcers?
Normal wound healing follows a well-organised process with several stages: haemostasis, inflammation, formation of new tissue (proliferation) and final remodelling.
These stages allow the skin to return to its normal appearance and function. However, in the case of chronic wounds such as venous ulcers, this process is disrupted. The wound remains stuck in a prolonged phase of inflammation, preventing progress to the next stages and slowing or even preventing complete healing.
This is why, according to the CEAP classification, venous leg ulcers can be classified as healed (C5) or unhealed (C6) depending on how long the ulcer persists without improvement.
At each stage of healing, different cells such as leukocytes (white blood cells), platelets, fibroblasts, muscle cells etc. release a wide variety of biomolecules (such as growth factors, proteins and enzymes). These substances play a key role in enabling the wound to progress from one phase to another until it heals.
Disruption of these mechanisms can slow down ulcer healing, leading to chronicity and complications.
Leg ulcer FAQs :
Although venous leg ulcers are not life-threatening, they do have a serious impact on patients' quality of life. If left untreated, it can lead to serious infections, impair quality of life through pain and physical limitations, and have a high risk of recurrence, even after healing. Certain risk factors such as advanced age, obesity and chronic venous insufficiency contribute to prolonged healing times and increase the chances of recurrence. Medical follow-up is therefore essential to avoid these complications.
Venous and arterial ulcers are different types of leg ulcer with different causes and treatments.
A venous ulcer is a chronic wound that develops mainly as a result of venous insufficiency. It typically occurs on the lower leg, often around the ankle. These ulcers have a characteristic appearance: a shallow sore with an irregular shape and heavy discharge. Patients may experience associated symptoms such as a feeling of heaviness in the leg, swelling (oedema) and changes in the appearance of the skin. They are less painful with the leg elevated and require compression treatment.
Arterial ulcers are caused by poor blood circulation in the arteries (e.g. due to cholesterol deposits), resulting in reduced blood flow and therefore reduced oxygenation and nutrient supply to the tissues(5,12). It is often located on the toes, the heel or the outer edge of the foot. It is regular in shape with smooth, well-defined edges, often without exudate (dry) and very painful(5). Treatment is aimed in particular at improving arterial blood circulation.
Correct diagnosis is crucial to appropriate treatment.
The first signs of a leg ulcer, particularly a venous ulcer, may appear gradually and require prompt attention to prevent worsening.
Patients often feel a sensation of heaviness or swelling in the leg. Another early sign is skin discolouration, with brownish or reddish patches around the ankle.
The skin often becomes dry, itchy and irritated. Moderate pain or discomfort in the affected area may also be present, often relieved by elevating the leg. Finally, the fragile skin may tear easily, and small wounds that do not heal may appear, developing into chronic ulcers if left untreated.
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Krizanova, O., Penesova, A., Hokynková, A., Pokorná, A., Samadian, A., & Babula, P. (2023). Chronic venous insufficiency and venous leg ulcers: Aetiology, on the pathophysiology-based treatment.. International wound journal. https://doi.org/10.1111/iwj.14405.
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Eberhardt, R., & Raffetto, J. (2019). Chronic venous insufficiency.. Circulation, 130 4, 333-46 . https://doi.org/10.1161/CIRCULATIONAHA.113.006898.
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Pugliese, D. (2016). Infection dans les ulcères veineux de jambe : considérations pour une gestion optimale chez les personnes âgées. Médicaments et vieillissement , 33, 87-96. https://doi.org/10.1007/s40266-016-0343-8 .
