Wounds on the lower leg that will not heal are very common and it is estimated that at any one time 1% of Australians have a chronic leg ulcer. They often occur after minor injury but can occur for no obvious reason and if not treated properly they can persist for decades or else continually heal but break down again.
Not all leg ulcers are the same and it is essential that they are properly investigated so that the correct treatment is instituted or they will not heal.
There are 4 major causes for the poor healing:
1) The most serious problem is a lack of blood supply to the leg (arterial insufficiency). This usually occurs in people who have a history of cardiovascular disease with previous heart attacks, strokes, hypertension, high cholesterol levels, diabetes and those who smoke. It also occurs in people who do very little walking exercise. These ulcers tend to be very painful at night and occur particularly on the toes and heel but can also occur on the lower leg.
2) Leg swelling is the most common cause for slow healing. Swelling may be due to varicose veins or previous deep vein thrombosis but may also just be due to a lack of exercise and long periods of standing or sitting. Obesity is often a contributing factor. These ulcers are found on the lower leg and seldom on the foot and they are not painful at night but tend to cause pain on getting up in the morning or by the end of the day when the leg is most swollen. They can become very large and usually produce a great deal of fluid.
3) Loss of sensation in the foot. Sensory neuropathy is most common in diabetics but can occur due to excessive alcohol intake and Vitamin B12 deficiency. Along with the lack of sensation there is usually a deformity of the foot and ulcers appear at pressure areas – usually on the sole of the foot or over prominent bones. They are never painful.
4) Skin cancer. Australia has the highest rate of skin cancer in the world. The legs are often exposed to the sun and are therefore at risk of developing skin cancer. Any ulcer that does not respond to other treatment or that looks suspicious with raised edges should be biopsied to check for cancer.
There may be one of more of these causes involved in a chronic ulcer.
Treating Leg Ulcers
Antibiotics and dressings do not cure leg ulcers!
Treatment must be directed towards fixing the cause for the ulcer.
Legs that have a poor blood supply will need intervention to restore the blood flow. This is usually done by angioplasty and stenting but occasionally bypass surgery is required.
Leg swelling must be controlled and there are a number of options. Compression bandages are usually used initially as they are the most effective means of controlling leg swelling. They cannot be taken off and must be kept dry so that showering is difficult. The bandages have to be applied by trained nurses and they are usually changed twice weekly. They are replaced by compression stockings as soon as possible but many people have trouble getting the stockings on and off. Another option is the intermittent compression pump but this can only be used while sitting or standing and so is only suitable for people that do not do much walking.
Neuropathic pressure ulcers require either surgery to alter pressure areas in the foot or else a total contact plaster cast that will relieve the area from pressure to allow healing to occur.
Ulcers that are due to skin cancer have to be surgically removed and a skin graft may be required to cover the resulting defect.
The South Sydney Vascular Centre runs regular Leg Ulcer Clinics to assess and treat people with ulcers and then help them avoid a recurrence.
How we can help
Unless the underlying conditions that contribute to your leg ulcer are properly identified the correct treatment cannot be instituted. The most important first step is assessment of blood supply and an arterial ultrasound may be required.
If there is a need for surgery then this will be arranged.
If the problem is due to leg swelling then we will identify the cause for the swelling and help you to find the easiest and best way to control the leg swelling. This is easier than it sounds and often involves a team of people.
Neuropathic ulcers require a multidisciplinary team including orthotists, foot wear specialists, podiatrists and physiotherapists. We work closely with the High Risk Foot Clinic at St. George hospital to this end.