Foot and leg ulcers - Lloydspharmacy.com Health

Reviewed by Dr Patricia Macnair, GP

Ulcers are breaks in the layers of the skin that fail to heal. They may be accompanied by inflammation.

Sometimes they don't heal and become chronic. Chronic foot and leg ulcers mainly affect the elderly.

People with diabetes are at special risk of developing foot ulcers, and foot care is an important part of diabetes management.

What causes ulceration?

The most common cause of chronic leg ulcers is poor blood circulation in the legs. These are known as arterial and venous leg ulcers.

Other causes include:

injuries – traumatic ulcers
diabetes – because of poor blood circulation or loss of sensation (nerve damage) resulting in pressure ulcers
certain skin conditions
vascular diseases (stroke, angina, heart attack)
tumours
infections.

Arterial leg ulcers

Approximately 10 per cent of all leg ulcers are arterial ulcers.

Feet and legs often feel cold and may have a whitish or bluish, shiny appearance.

Arterial leg ulcers can be painful. Pain often increases when your legs are at rest and elevated.

You can reduce pain by sitting on the edge of the bed with your feet on the floor. Gravity will then cause more blood to flow into your legs.

What causes arterial leg ulcers?

Diabetes and ulcers

The long-term effect of diabetes on the nerves causes a reduction in sensation in the feet.

This increases the likelihood of accidental trauma to the feet, which makes ulcers more likely to appear.

But these ulcers are often neglected because they don't cause pain.

If ulcers aren't treated, they can lead to more serious problems, such as gangrene and even amputation.

Arteries are the tubes that carry oxygen-rich blood from the heart to the body's tissues. The tissues receive oxygen and nutrients from the blood.

The used blood, which now contains carbon dioxide and other by-products, is carried via the veins from the tissues back to the heart.

Arterial leg ulcers are caused by poor blood circulation as a result of narrowed arteries due to atherosclerosis where a fatty deposit builds up inside the arteries.

As a result of the limited blood supply, the tissues are starved of the oxygen and nutrients they need and so break down, forming an ulcer.

Arterial ulcers may also be called ischaemic ulcers (ischaemia meaning low blood supply).

People with diabetes have a much increased likelihood of developing atherosclerosis.

But diabetes can also directly damage the small blood vessels.

This means people with diabetes have a much increased risk of developing arterial ulcers.

What can trigger or worsen arterial leg ulcers?

Smoking.
High blood pressure.
Diabetes.
Arthritis (rheumatoid arthritis).
Previous problems from leg ulcers, which leave the tissues damaged and scarred.
Coronary heart disease, including coronary thrombosis (blood clots blocking the arteries of the heart).
Atherosclerosis in the legs.

What can I do to prevent arterial leg ulcers?

Claudication

People with arterial leg ulcers often suffer from intermittent claudication.

The condition causes cramp-like pains in the legs when walking.

This is because the leg muscles don't receive enough oxygenated blood to function properly.

Claudication pain usually goes away if you stand still for a few minutes (as this allows the exercising muscle time to refresh its oxygen supply).

But it is a sign or severe narrowing of the arteries due to atheroscleorsis, and it needs to be assessed by a doctor.

Not all people with intermittent claudication have leg ulcers.

Stop smoking and lose weight if you are overweight.

Reduce the amount of fat in your diet and eat more fruit and vegetables.

Aim to keep your cholesterol levels low (many people need regular medication to do this).

Exercise as much as possible. By exercising, you force your blood vessels to form new branches, improving the blood circulation in your legs.

It's fine if your legs hurt a little when you exercise, but it mustn't make you feel unwell.

If you get pain in your legs when exercising, which is severe enough to force you to stop, you should talk to your doctor because this may be a sign that atherosclerosis is already seriously narrowing your arteries.

This symptom is known as intermittent claudication (see below).

Try this exercise while sitting down: move your feet around in circles, then up and down.

This activates the venous pump. It's also helps people with venous leg ulcers.

Take good care of your feet.

Make sure shoes fit correctly and are not too small.
Keep your feet warm and try to avoid injuries to your feet and legs.
Examine your feet and legs daily for any changes in colour or the development of sores.
Visit a chiropodist regularly.
Keep any dry patches of skin well moisturised to prevent the cracks and breaks that can develop into ulcers.

Venous leg ulcers

Approximately 70 per cent of all leg ulcers are venous ulcers.

A leg with venous problems has a very characteristic appearance.

The leg is swollen.
The skin surrounding a venous ulcer is dry, itchy and sometimes thickened and brownish in colour. If the swelling, or oedema as it is called, is very bad then the skin may be stretched smooth and shiny.
eczema may appear (varicose eczema), where the skin becomes cracked and scaly.
The ulcer has a weeping, raw appearance and is usually painless unless infected.
If infected the ulcer may give off a very unpleasant smell, and ooze pale yellowish green fluid.
Venous leg ulcers are often located just above the ankle, typically on the inside of the leg.

What causes venous leg ulcers?

Most of venous leg ulcers occur because the valves connecting the superficial and deep veins are not functioning properly, so blood doesn't drain from the legs as it should.

As a result, the fluid in the tissues of the leg builds up causing an increase in pressure that prevents a healthy flow of oxygen and nutrients through the tissues.

The venous system is made up of superficial and deep veins:

superficial veins are located between the skin and the muscles
deep veins are located between the muscles.

Superficial and deep vein systems are connected to each other by veins that have one-way valves.

These valves normally ensure that blood flows from the superficial veins to the deep system.

Failure of these valves (which may develop with age-related changes in the tissues what cause the valves to become thin and weak) causes blood to flow from the deep veins back out to the superficial ones – a major cause of varicose veins.

The problem is aggravated by the effects of gravity which forces blood to pool in the lower leg.

When you walk or exercise, the calf muscles push venous blood back up, against gravity, to the heart, so exercise helps to control fluid and pressure in the legs and reduces the risk of venous ulcers.

Sitting with your legs raised on a stool or cushion can also help as this reduces the effects of gravity.

Many old people sleep in chairs rather than going to bed at night. But sleeping with legs down on the ground increases the risk of venous ulcers.

The elderly should be encouraged to sleep horizontally and even take a nap in bed during the afternoon if they have problems with venous ulcers.

What can trigger or worsen a venous leg ulcer?

Previous ulcers that may have damaged part of the venous system.
A fracture or other injuries.
A blood clot in the deep veins (deep vein thrombosis).
Surgery.
Work that requires a lot of sitting or standing.
Inflammation in the veins (phlebitis), especially in the deep veins.
Pregnancy – the more pregnancies, the higher the risk.
Obesity.

What can I do to prevent venous leg ulcers?

Activate your calf muscles regularly by walking and exercising.
Reduce the amount of fat in your food. Eat more fruit and vegetables.
If you are overweight, losing weight will help prevent ulcers.
Sit with your legs raised whenever you have the opportunity – above heart level if possible.
Avoid sitting with your legs crossed. This impairs blood circulation.
If your work requires a lot of standing or sitting, try to vary your stance as much as possible. Walk about from time to time, if you can.
If you have to stay seated for a long time, move your feet up and down occasionally.
Support stockings may be useful, but talk to your doctor or practice nurse first.
Inspect your feet and legs daily. Look for sores or changes in colour.
Visit your chiropodist regularly.

How are leg ulcers diagnosed?

Diagnosis is usually made on the basis of the appearance and location of the ulcer.

With arterial leg ulcers, the arteries themselves will be examined and investigated to establish their condition.
With venous leg ulcers, an ultrasound scan of the deep veins may be necessary to detect deep vein thrombosis or measure pressures in the blood vessels and tissues.

In all cases, the blood pressure in your lower legs should be compared with the blood pressure in your arm.

This will show the degree of impairment in the blood supply to your legs. Ask your GP about this check.

How are leg ulcers treated?

Treatment depends on the factors that cause the ulcer or have prevented healing.

Once these factors are under control, for example the blood sugar level in diabetes, the ulcer should heal by itself.

Treatment may involve wound cleansing, anti-inflammatory treatment and application of dressings.

So long as there is no arterial disease, venous leg ulcers will benefit from elevation and compression dressings.

Arterial ulcers may benefit from vascular surgery: the insertion of new leg arteries, for example, or balloon angioplasty – a procedure that relieves narrowing and obstruction of the arteries.

Sometimes it's necessary to close the ulcer by means of plastic surgery. This involves taking skin from somewhere else on your body and placing it over the ulcer.

If ulcers are caused by an underlying disease, it's important this is treated – for example medication may be recommended to reduce cholesterol levels in order to reduce the risk of atherosclerosis and improve blood flow to the tissues.

In the long term

Leg ulcers have a tendency to recur in elderly people, and sometimes may require years of therapy.

Arterial leg ulcers and intermittent claudication are serious warning signs. If left untreated, they may cause further complications and require surgical intervention.

Other people also read:

Deep vein thrombosis (DVT): why is it dangerous?

Varicose veins: when do I seek help?

Angina pectoris: what causes angina?

Based on a text by Dr Flemming Andersen and Hans Gad Johannsen, orthopaedic surgeon

Last updated 18.01.2011

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