Venous Ulcer (Leg Ulcer)

A venous ulcer is a chronic leg wound that does not heal for a long period of time, developing as a result of inadequate functioning of the superficial or deep veins in the legs (chronic venous insufficiency). These wounds, usually seen around the ankle and especially on the inner side, are the most common type of chronic wound in the lower extremities. They are also known as "leg ulcers" or "varicose ulcers" among the public. If left untreated, they significantly reduce quality of life and can lead to infection and tissue loss.

What Is a Venous Ulcer?

A venous ulcer is an advanced stage of chronic venous insufficiency that develops as a result of the veins in the legs being unable to return blood to the heart. Blood and fluid accumulating in the legs:

  • Disrupts tissue oxygenation
  • Causes inflammatory reactions under the skin
  • Disrupts skin nutrition
  • Eventually causes skin breakdown and open wounds

Venous ulcers constitute approximately 70-80% of all leg ulcers and are seen in 1-3% of the population. They are more commonly encountered in women over 50 years of age.

Venous System and Its Functioning

There are three main venous systems in the legs:

Superficial Venous System

  • Located under the skin
  • Great saphenous vein and small saphenous vein
  • Plays a role in varicose vein formation

Deep Venous System

  • Located deep within muscles
  • Carries the vast majority of blood in the legs
  • Its blockage leads to serious consequences

Perforating Veins

  • Connecting vessels between superficial and deep systems
  • Ensure blood flow from surface to deep

There are three basic mechanisms for blood return to the heart in the legs:

  1. Heart pump: Sends blood throughout the body
  2. Muscle pump: Muscles in the leg compress veins, sending blood upward
  3. One-way valves: Prevent blood from flowing backward

Disruption of these mechanisms leads to venous insufficiency and eventually ulcers.

Causes of Venous Ulcer

Main Causes

Chronic Venous Insufficiency

The most important cause:

  • Varicose veins (enlarged superficial veins)
  • Venous valve disorder
  • Deep vein thrombosis (DVT) history
  • Congenital venous anomalies
Post-Thrombotic Syndrome
  • After previous deep vein thrombosis
  • Permanent damage to veins
  • Valve dysfunction
  • The cause of 25% of venous ulcers
Other Causes
  • History of leg fracture or trauma
  • Long-term immobility
  • Post-surgical thrombosis
  • Congenital venous anomalies

Risk Factors

General Risk Factors

  • Age: Significant increase over age 50
  • Gender: More common in women
  • Family history: Genetic predisposition
  • Obesity: Increases venous pressure in the legs
  • Pregnancy: Pelvic pressure increase
  • Multiple births
  • Aging: Vessel structure weakens

Occupational Risk Factors

  • Prolonged standing (teachers, salespeople, waiters)
  • Prolonged sitting work (drivers, office workers)
  • Jobs requiring heavy lifting

Medical Risk Factors

  • Deep vein thrombosis history
  • Pulmonary embolism history
  • Thrombophlebitis (superficial vein inflammation)
  • Leg trauma or fractures
  • Previous leg surgery
  • Congestive heart failure
  • Liver diseases
  • Kidney diseases

Lifestyle

  • Smoking
  • Sedentary lifestyle
  • Inadequate exercise
  • High salt consumption
  • Tight clothing

Symptoms of Venous Ulcer

Early Stage Symptoms

General Leg Complaints
  • Sensation of heaviness and fatigue in legs
  • Edema (swelling) that increases in the evening
  • Cramps in the legs (especially at night)
  • Itching
  • Burning sensation
  • Restless leg syndrome
Skin Findings
  • Visible varicose veins
  • Darkening of skin color (especially around the ankle)
  • Brown-bronze pigmentation (hemosiderin deposition)
  • Skin dryness and scaling

Advanced Stage Symptoms

Lipodermatosclerosis
  • Hardening under the skin
  • Skin taking on an "inverted bottle" appearance around the ankle
  • Loss of skin elasticity
Eczema (Venous Eczema)
  • Redness and itching
  • Scaling and skin peeling
  • Local skin inflammation
  • Sometimes allergic reactions
Atrophie Blanche
  • Small white areas on the skin
  • Pre-ulcer sign
  • Fragile skin

Ulcer Stage

Classic Appearance
  • Location: Most commonly around the inner ankle
  • Wound shape: Irregular, superficial
  • Wound base: Usually pink or yellowish
  • Wound edge: Slightly raised, irregular
  • Wound surroundings: Pigmented, hard, lipodermatosclerotic
  • Discharge: Yellowish, abundant
  • Pain: Usually mild-moderate, decreases when lying down
Accompanying Symptoms
  • Significant leg edema
  • Wide varicose veins
  • Skin color changes
  • Foul odor (when infected)
  • Fever (sign of infection)

CEAP Classification

Standard classification of chronic venous diseases:

Clinical Classification

  • C0: No visible venous disease
  • C1: Telangiectasias or reticular veins (capillaries)
  • C2: Varicose veins
  • C3: Edema
  • C4a: Pigmentation, eczema
  • C4b: Lipodermatosclerosis, atrophie blanche
  • C5: Healed venous ulcer
  • C6: Active venous ulcer

Diagnostic Methods

Medical History

Detailed inquiry:

  • Duration and characteristics of complaints
  • History of previous wounds
  • Deep vein thrombosis history
  • Surgery and trauma history
  • Family history
  • Occupational information
  • Accompanying diseases
  • Medications used

Physical Examination

  • Examination in standing and lying positions
  • Evaluation of leg skin color
  • Edema evaluation
  • Detailed wound examination
  • Pulse check
  • Leg circumference measurement

Imaging Methods

Color Doppler Ultrasonography

The gold standard diagnostic method:

  • Evaluation of vein structure
  • Measurement of valve function
  • Detection of reflux (backward blood flow)
  • Presence of deep vein thrombosis
  • Superficial vein disease evaluation
Venous Plethysmography
  • Objective measurement of venous function
  • In complex cases
MR/CT Venography
  • Vein anomalies in the pelvic region
  • In complex cases
  • Pre-surgery planning
Conventional Venography
  • Rarely used today
  • Preferred in special situations

Wound Evaluation

  • Wound size measurement
  • Photography (for follow-up)
  • Wound culture (suspected infection)
  • Biopsy (in atypical cases)

Ankle-Brachial Index (ABI)

  • Evaluation of the arterial system
  • Detection of mixed (arterial + venous) ulcers
  • Required before compression therapy
  • Normal value: 0.9-1.3

Venous Ulcer Treatment

Treatment requires a multidisciplinary approach. Main treatment goals:

  • Reduce venous hypertension
  • Control edema
  • Heal the wound
  • Prevent recurrence
  • Improve quality of life

Compression Therapy

The cornerstone of venous ulcer treatment. It supports venous return by applying external pressure to the legs.

Types of Compression
Elastic Bandages
  • Classical method
  • Single-layer or multi-layer
  • Requires professional application
  • Daily or every few days change
Compression Stockings
  • Mild (<20 mmHg): Preventive
  • Moderate (20-30 mmHg): Mild venous disease
  • High (30-40 mmHg): Active ulcer treatment
  • Very high (>40 mmHg): Advanced cases
Multi-Layer Bandage System (4-Layer Bandage)
  • The most effective compression method
  • High pressure (40 mmHg)
  • Applied for one week
  • Gold standard in active ulcer treatment
Pneumatic Compression Devices
  • Applies intermittent pressure
  • Mimics muscle pump
  • Can be used at home or in clinic
Compression Therapy Warnings
  • Cannot be used in arterial insufficiency (ABI <0.7)
  • Correct pressure is important
  • Should be applied under physician follow-up
  • Patient education is essential

Wound Care

Debridement

Dead tissue cleaning accelerates wound healing:

  • Surgical debridement: Fast, effective
  • Autolytic debridement: With wound dressings
  • Enzymatic debridement: Special ointments
  • Mechanical debridement: During dressing changes
  • Larval therapy: In special cases
Wound Dressings

Selected according to wound type and stage:

  • Hydrocolloid dressings: Low-moderate exudating wounds
  • Foam dressings: Heavy exudating wounds
  • Alginate dressings: Heavily exudating, bleeding wounds
  • Hydrogel: Provides moisture for dry wounds
  • Silver dressings: In infected wounds
  • Activated carbon dressings: For odor
Moist Wound Healing
  • Fundamental principle of modern wound care
  • Keeping the wound moist accelerates healing
  • Cell migration is supported
  • Autolytic debridement

Infection Management

Infection is seen in approximately 20-50% of venous ulcers:

  • Wound culture is taken
  • Targeted antibiotic therapy
  • Topical treatment in mild infections
  • Systemic antibiotics in severe cases
  • Regular wound cleaning

Treatment of Venous Insufficiency

Treatment of underlying venous disease:

Treatment of Varicose Veins
Endovenous Laser Treatment (EVLA)
  • Minimally invasive method
  • Closes the affected vein with laser
  • Can be done as outpatient
  • High success rate (95%)
  • Fast recovery
Radiofrequency Ablation (RFA)
  • Effect similar to laser
  • Vein closure with heat
  • Low complications
  • One of the preferred methods
Sclerosant Substance Injection (Sclerotherapy)
  • Foam or liquid sclerosant
  • For small varicose veins
  • Applied under Doppler guidance
  • Multiple sessions may be required
Conventional Surgery (Stripping)
  • Classical method
  • Removal of the affected vein
  • Requires general anesthesia
  • Has given way to minimally invasive methods today
Mechanochemical Ablation (MOCA, ClariVein)
  • New minimally invasive method
  • Mechanical and chemical effects together
  • Does not require anesthesia
Cyanoacrylate Adhesive (VenaSeal)
  • Vein closure with medical adhesive
  • Does not require compression stocking
  • Fast recovery
Perforating Vein Surgery
  • Closure of affected perforating veins
  • Endoscopic or surgical approach
  • In resistant ulcers

Surgical Wound Treatment

Surgical options for non-healing wounds:

Skin Graft
  • Transfer of skin from healthy area to wound
  • In large and long-standing wounds
  • Body's own skin (autologous graft)
  • Artificial skin and tissue equivalents
Flap Surgery
  • Wound closure with adjacent healthy tissue
  • In large and complex wounds
  • May require plastic surgery
Negative Pressure Wound Therapy (VAC)
  • Negative pressure on the wound with a vacuum system
  • Accelerates wound healing
  • Increases granulation tissue
  • Reduces edema

Adjuvant Treatments

Medication
  • Pentoxifylline: Improves microcirculation
  • Diosmin/hesperidin: Supports venous tone
  • Aspirin: Prevents microcoagulation
  • Zinc sulfate: For wound healing
  • Antibiotics: In case of infection
Hyperbaric Oxygen Therapy
  • Breathing oxygen under high pressure
  • Increases tissue oxygenation
  • In resistant cases
Physical Therapy
  • Leg exercises
  • Lymphatic drainage massage
  • Supports muscle pump

Lifestyle Recommendations

Leg Care

  • Keeping legs elevated (several times during the day)
  • Regular walking
  • Exercises that activate the muscle pump
  • Avoiding prolonged standing or sitting

Nutrition

  • Healthy weight control
  • Low-salt diet
  • Fiber-rich foods
  • Adequate protein intake
  • Plenty of fluid consumption

General Recommendations

  • Smoking cessation
  • Avoiding tight clothing
  • Limiting high-heeled shoes
  • Avoiding hot baths
  • Regular health check-ups

Exercise

  • Walking: 30-45 minutes a day
  • Swimming: Good for edema
  • Cycling: Low-impact exercise
  • Ankle exercises: Can be done even while sitting

Complications

Acute Complications

  • Wound infection
  • Cellulitis (skin inflammation)
  • Sepsis (rare, in serious cases)
  • Severe bleeding (varicose vein bleeding)
  • Acute thrombosis

Chronic Complications

  • Recurrent ulcers
  • Progression of lipodermatosclerosis
  • Permanent pigmentation
  • Contractures
  • Marjolin's ulcer: Skin cancer development in long-standing wounds (rare but serious)
  • Leg deformities
  • Significant decrease in quality of life

Healing Process and Recurrence

Healing Time

Venous ulcer healing may take a long time:

  • Small ulcers: 4-6 weeks
  • Medium-sized ulcers: 3-6 months
  • Large or chronic ulcers: 6-12 months or longer
  • Treatment-resistant ulcers: Longer than 1 year

Recurrence Rates

  • 50-70% recurrence rate within 5 years
  • Lower in cases with adjuvant treatment
  • Lifestyle changes reduce recurrence
  • Compression stocking use is important

Recurrence Prevention Approach

  • Lifelong compression stocking use
  • Treatment of varicose veins
  • Regular check-ups
  • Skin care
  • Continuation of lifestyle changes

Prevention of Venous Ulcer

General Measures

  • Healthy weight control
  • Regular exercise
  • Smoking cessation
  • Active lifestyle

Occupational Measures

  • Foot changes during prolonged standing
  • Foot elevation during prolonged sitting
  • Regular breaks
  • Compression stocking use

Skin Care

  • Skin moisturizing
  • Protection from trauma
  • Early problem detection
  • Appropriate footwear selection

Special Measures in Risk Groups

  • Prophylaxis in previous DVT patients
  • Regular follow-up of those with family history
  • Compression stocking in pregnancy
  • Early mobilization after surgery