Causes and Treatment of Venous Insufficiency Ulcers Protection Status
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superficial venous insufficiency ulcer

by Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS

Lower extremity venous insufficiency ulcers represent approximately 80% of the leg ulcers typically seen in wound care facilities. The following statistics help to bring home the seriousness and chronicity of this common health problem:

  • Healing time for venous insufficiency ulcers averages 24 weeks
  • Approximately 15% of these ulcers will never heal
  • In 15 to 71% of cases of venous insufficiency ulcers, the ulcers represent a recurrent lesion
  • It is estimated that the cost of treating venous insufficiency ulcers is 1 to 5 billion dollars every year

What Causes Venous Insufficiency Ulcers?

There are two important (and sometimes indistinguishable) causes of venous insufficiency ulcers. One half to two-thirds of venous insufficiency ulcers result from progressive disease of the leg veins. The course of such disease is predictable: it starts with the development of varicose veins caused by refluxing of blood within the veins due to incompetent valvular structures. These varicosities may cause variable swelling and discomfort. As disease progresses, skin changes occur (hemosideran staining and dermal and subcutaneous thickening and scarring) which eventually lead to the formation of a venous insufficiency ulcer. The course of the disease often culminates in ulcer formation in patients in their 60s and 70s.

Approximately one-third to one-half of venous insufficiency ulcers occur after the patient experiences DVT (deep vein thrombosis). DVTs may cause the process of ulcer formation to occur more quickly than in primary venous insufficiency as described above. Patients who have had a DVT may also present with hemosiderin staining, swelling and discomfort, making it difficult to distinguish post-phlebotic ulcer formation from ulcer formation stemming from venous insufficiency.

How are Venous Insufficiency Ulcers Treated?

Compression Therapy
Compression therapy is standard in healing venous insufficiency ulcers; however, before compression therapy is begun, arterial and venous circulation should be evaluated thoroughly to ensure that compression therapy is safe. This can be done by measuring ABIs (ankle brachial pressure index) or by Doppler studies of the lower extremities. Ace wraps are one simple method of compression that can be used, and offers the advantage of ease of application for some patients. Unna boots, which provide compression and wound care together, may also be used. In addition, patients may be measured and fitted for elastic compression stockings. These are commonly used, but may be difficult for some patients to don and doff.

Wound Treatment
The following wound preparations may be recommended:

  • Topical or systemic antibiotic therapy for wounds that are infected
  • Debridement of exudates and fibrous tissue to stimulate the growth of new epithelium
  • Absorbent dressings for heavily draining ulcers
  • Acetic acid
  • Silver nitrate dressings
  • Calcium alginate dressings
  • Proteolytic enzyme agents
  • Synthetic occlusive dressings

Moist wound healing is the key to healing venous insufficiency ulcers, facilitating epidermis formation over moist granulation tissue.

Other Treatments
When ulcers fail to heal despite aggressive wound treatment and compression, such as hyperbaric oxygen treatment, skin grafting and systemic therapy with Pentoxyfylline, which promotes blood flow to areas with reduced blood flow (ischemia).

Venous insufficiency ulcers represent a challenge to healthcare professionals who care for patients with these wounds. A multi-pronged approach is often necessary, including scrupulous wound care, compression therapy and referral to a surgeon when necessary for chronic non-healing wounds.

Beylin, M. (2004). Treating venous stasis ulcers in the lower extremity. Podiatry Today, 10 (17).
Cleveland Clinic. Lower Extremity (Leg and Foot) Ulcers. Cleveland Clinic. Updated November 2010. Accessed May 14, 2015.
Kistner, R., Shafritz, R., Stark, K., & Warriner, R. (2010). Emerging treatment options for venous ulceration in today’s wound care practice. Ostomy Wound Management, 56 (5), pg. 1-11.

Image Credit: Medetec (

Editor's Note: This article was originally published on February 17, 2011 and has been updated for accuracy and comprehension.

About The Author
Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS is a Certified Wound Therapist and enterostomal therapist, founder and president of, and advocate of incorporating digital and computer technology into the field of wound care.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.


Compression therapy is extremely important. I believe it can be the difference maker in whether a wound heals or not. What recommendation would you have for how long a compression sock maintains its usefulness. I have found some insurance plans allow only four new garments a year. Will a knee high compression stocking hold its proper compression for three months, I don't think so. What are your thoughts on the time a compression garment can retain its proper compression?

I was diagnosed 11 years ago with venous stasis abd have managed to work...sales, and on my feet 9 hours a day...and live a "normal" life.
18 months ago I used a Unna boot to heal a small ulcer..1/2 the size of a dime...when I removed the boot, to my horror, the ulcer had gotten bigger.
I the following months I've tried to get it to scab and it wouldn't...I've tried Silvadene...Puracor AG...all to no avail. As the surrounding tissue becomes compromised, it too, eventually becomes ulcerated.
I have read that compression must be used in the treatment of these ulcers, but the pain is sooo intense I cannot even think straight, let alone work.
I have developed a system to elevate the bandage off the wound bed as every time I would remove the bandages it just made the wound bigger...non-stick bandages are a lie!
My biggest question is would topical steroids help keep the skin from deteriorating further and help promote some healing here?

I know I should file disability but because of income restrictions I cannot...not unless I want to be homeless.
Any advice would be welcome....

Have you tried Zim's Wound Care Gel? It goes on as a thick gel and solidifies very fast. You can place a nonstick bandage over that and it will remove quite easily. The gel is collagen based and the package states it is for healing open wounds including venous ulcers. good luck.

Sounds to me that you would be able to qualify for a pneumatic gradient compression pump with adjustable pressure in each chamber to avoid the pressure on the ulcer directly. Do you have insurance/Medicare? You need the compression. This would be a way to get it with less pain.

The longer the disease is present, the more incompetent the veins can become. Sometimes no matter how adequate the therapy, further intervention may be necessary. Ruling out an infection in the wound would be the first course of action. If there is no infection of high level of colonization, and you still are responding minimally to optimal compression (30-40mmHg), then the next logical step would be for you to seek out a vascular specialist, trained in venous procedure, have a vein mapping study performed, to determine exactly which vein(s) is (are) the major offenders, and if they are located in a zone which would respond to ablation therapy. This is typically a simple day procedure, which may assist in correcting the non-healing issue at this time. But ongoing stocking therapy is important for maintenance. Good luck.

I had severe ulcers that led to cellulitis. I believe that I may have contacted the cellulitis bacteria from my neighbors home. It eventually got into one of my ulcers and ,oh boy, did the ol' rodeo start then. My ulcers increased and the cellulitis was spreading. The wounds were constantly draining. My neighbor with the cellulitis decided to come free and said that the leaking ulcers and cellulitis wounds could be helped. I was given a site to log onto and it had a half baked home remedy. I had my doubts but I tried it anyway. It's simple to make. It's called Dakin's Solution. You can find the recipe easy enough by just typing Dakin's Solution unto your search bar, or go to It took several days, but I'll be damned if it didn't start working. It dried out the ulcers and even began to dry out the cellulite wound. It's been six months and my legs are back to normal. Except for the scarring, no one would be able to tell I had severe problems at one time. Problems and pain so horrific that I would sometimes cry. I took my pain med's as prescribed and my antibiotics and a number of other med's. They all seemed to have worked in harmony though. My medical team was magnificent with all the information and help they gave me. Well, good luck John. What worked for me, I hope and pray will work for you. P.S. By the way John, be sure to clean your wounds three times a day. I know it may be extremely painful, but it will have to be done. I was told to treat it like it was a severe burn treatment.

I have a severe leg ulcer that first began in 1988 and have been through just about every treatment option extant from Unnaboots
to negative pressure to electro-stimulation and am most likely facing lower leg amputation. I have spent over $30 thousand of
my own money in medicare and cobra co-pays. Medihoney was recently recommended as a dressing but I developed a dark
grey-green infection which Dakin's solution got rid of. Medihoney appears to be greatly exaggerated in its antibacterial ability.

According to one study I read, the choice of topical dressings seems not to make much difference. I disagree. Also, if
silver compounds are so often recommended, why not zinc oxide (as used in Unnaboots) at a fraction of the cost?

Hello there! This article could not be written any better!
Reading through this article reminds me of my previous roommate!

He constantly kept preaching about this. I'll forward this article to him.
Pretty sure he's going to have a good read.
Thanks for sharing!

I appreciate Laurie for taking the time to update this important post. Venous Ulcers are among the most difficult of all chronic wounds to manage. Fortunately, this is an area that has received good quality research attention for many years, so much of what was said in 2011 is applicable today.

Several years ago I created a comprehensive heavily-referenced clinical education booklet for nurses to use as a guide for teaching. The booklet contains a detailed explanation of the causes and prevention of VLUs, but it also contains evidence-based detailed treatment options, as well as a Procedure and Summary Protocol with a Decision Tree based upon ABI, etc. As of last week, this booklet is available free online at: (click on Clinical Education, then Venous Leg Ulcer Clinical Education to open the PDF). I am excited that I can now make it available to anyone with an internet connection!

Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA
Clinical Research & Education Liaison, and Charity Liaison
Ferris Mfg. Corp. and
Independent Nurse Researcher in Tropical Developing Countries

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