Leg Ulcer - Find a Specialist and Get Information

“Ulcus cruris” is the medical term for a leg ulcer. “Ulcus” refers to a long-standing (= chronic), non-healing wound that continues to grow larger and deeper. “Cruris” is the medical term for the lower leg.

A leg ulcer in a very advanced stage © Source: Wikimedia

The prevalence of a leg ulcer in Germany is approximately 0.5–1 percent. In other words, 50–100 out of every 1,000 people in Germany suffer from a leg ulcer; a total of about 80,000 people are affected nationwide.

The likelihood of developing the condition is strongly age-dependent and rises to about 2.5 percent starting at age 70. Women are affected more frequently than men. While this leg condition is rare before the age of 40, the rate of people affected rises significantly, particularly after the age of 80.

The causes of the wound’s failure to heal vary. Often, pathological changes in the arteries and/or veins are the underlying cause. However, inflammation of both large and small blood vessels, as well as bacterial colonization, can also be causes of a leg ulcer.

The condition most commonly occurs on the lower leg, above the ankle. Large ulcers located on the inner side of the lower leg are usually of venous origin, particularly in cases of varicose veins or following thrombosis. In these cases, the leg ulcer is a consequence of chronic venous insufficiency (CVI) and is referred to as a venous leg ulcer.

If the wounds are located on the outer side of the lower leg, the cause is usually the arteries. Peripheral arterial disease (PAD) is particularly noteworthy in this context. Arteriosclerosis causes narrowing or blockages in the arteries, leading to a deterioration in tissue perfusion and a reduction in oxygen supply. This is referred to as a leg ulcer.

The tissue defect usually manifests as a painful wound that shows little tendency to heal.

The first visible sign of a venous leg ulcer is increased pigmentation (brown discoloration of the skin). This occurs because blood cells are forced through the vessel walls into the surrounding tissue due to increased pressure in the veins. There, they break down and become visible as a brown discoloration.

At the same time, yellowing of the skin and a condition known as “atrophie blanche” (whitish, thinned areas of skin) may occur. In addition, the spider-web-like vascular patterns (corona phlebectatica) characteristic of venous insufficiency can be seen on the inner ankle.

The brown discoloration of the skin is one of the first signs of a venous leg ulcer © Andrew | AdobeStock

Due to the impaired venous drainage, metabolic waste products can no longer be removed. As a result, skin cells die off (necrosis), leading to cracks and small injuries. 

Ulcer-like, slow-healing, and often painful wounds now form on the surface of the severely compromised tissue. The ulcers are initially small but, if left untreated, quickly grow into extensive ulcers affecting the entire lower leg.

An arteriosclerotic leg ulcer begins with a vascular occlusion. This leads to ischemia (insufficient blood flow) in the tissue, as well as tissue necrosis with ulceration.

As the disease progresses, pain during movement (intermittent claudication) sets in earlier and earlier. Later, it is noticeable even at rest and when the legs are elevated. The feet and legs are cold, blue, and livid (pale).

An arterial leg ulcer (ulcus cruris arteriosum) manifests primarily distally on the feet, toes, and heels. Arterial ulcers are also small and have a round outline with a pale wound bed, which is often covered with fibrin.

In general, all forms of leg ulcers are preceded by reduced blood flow to the affected lower leg tissue. Depending on the underlying cause of this poor blood flow, different forms of the condition are distinguished.

The cause of the reduced blood flow is usually venous insufficiency, which can be congenital or acquired. Venous insufficiency can result from

• chronic venous insufficiency,
• varicose veins (varicosus; varicose leg ulcer),
• postthrombotic syndrome (postthrombotic leg ulcer),
• or even pregnancy

.

Venous insufficiency leads to blood pooling in the leg veins. The veins dilate due to the increase in blood volume and develop varicose veins. This results in inflammatory processes and, in some cases, thrombus formation. The backflow also causes venous hypertension (high blood pressure), which gradually destroys the capillaries. Capillaries are the smallest blood vessels where the exchange of nutrients and gases takes place.

Edema—swelling of the tissues caused by fluid accumulation—forms in the ankle area. As the condition progresses, the edema develops into dermatoliposclerosis. Dermatoliposclerosis is a palpable hardening of the skin and subcutaneous tissue. These changes result in a reduced supply of oxygen and nutrients to the affected tissue.

In addition, a lower leg ulcer is caused by atherosclerosis of the lower extremities in about 10 percent of cases. In atherosclerosis, the arteries narrow, which can ultimately lead to complete occlusion of the vessel (peripheral arterial occlusive disease, PAD).

Ulcerated skin © ilusmedical | AdobeStock

Often, a mixed form with both venous and arterial causes—an ulcus cruris mixtum—is present. This is caused by the combined presence of PAD and CVI.

In about 10 percent of cases, the lower leg ulcer

• is caused by an accident (traumatic leg ulcer) or
• due to a tumor (ulcus cruris neoplasticum),
• an infection (infectious leg ulcer), or
• a systemic disease such as rheumatism (rheumatic leg ulcer)

.

In the case of a classic leg ulcer, the examination is performed as part of a visual diagnosis, that is, by the doctor’s visual inspection. Changes in the surrounding area are also important for the diagnosis.

Of course, other risk factors that may contribute to its development must be ruled out.

It is standard practice to photographically document the healing process of a leg ulcer. If the healing process exhibits unusual characteristics, tissue samples are occasionally taken and subsequently tested bacteriologically.

Local therapy begins with wound debridement. First, the necrotic tissue is removed under local anesthesia. Every effort is made to avoid excessive thinning of the lower leg fascia (debridement).

Extensive areas of necrosis are surgically removed. In cases of thin necrotic layers, removal is performed using enzymatic or physical debridement.

Special wound dressings are used in wound care, such as

• hydrocolloids,
• hydrogels,
• alginates,
• polyurethane foam.

They maintain a moist wound environment and promote wound healing.

In cases where the cause is venous (and arterial causes have been ruled out), compression therapy is the most important component of treatment for a leg ulcer. Compression stockings and compression bandages are used for this purpose. They minimize venous stasis and improve impaired venous return.

In addition, regular exercise is recommended to support the venous valves and reduce the backflow of blood via the calf muscle pump. Veins in which venous stasis is particularly pronounced can be removed via stripping, closed with a laser, or obliterated with medication.

If the cause is arterial, blood flow can be improved by 

• blood-thinning medications or 
• clot dissolution (lysis) or
• vascular surgery (bypass surgery, balloon dilation)

.

A leg ulcer is not just a case for a dermatologist. Depending on the underlying cause, the underlying condition should also be evaluated by

• a phlebologist (vascular specialist),
• diabetologists (diabetes mellitus), 
• oncologists (cancer), or
• internists (hypertension)

.

With consistent and early treatment, a leg ulcer usually heals completely within a few months. In general, the chances of healing are better for a venous leg ulcer than for an arterial leg ulcer.

However, the recurrence rate (reappearance) is significantly higher for venous leg ulcers. Recurrence means that the condition develops again after healing. To reduce the risk of recurrence, it is recommended to

• wearing properly fitted compression stockings,
• elevating the legs and avoiding crossing them, as well as
• changing your working posture periodically by alternating between standing and sitting.

The risk factors for a leg ulcer are

• Smoking
• Being overweight
• unhealthy diet
• Lack of exercise
• Genetic predisposition
• Diabetes mellitus (diabetes)
• high blood pressure (hypertension) as well as
• elevated blood lipid levels

As a preventive measure, the following is therefore recommended:

• Avoiding nicotine consumption
• Physical activity and regular exercise
• Weight loss
• A healthy and varied diet
• Regular checkups of the feet and legs
• Soft, well-fitting shoes
• Prevention of injuries