Venous Ulcers

Venous leg ulcerations affect approximately 1% of the U.S. population, with estimates ranging from 0.06% to 2% depending on the study methodology and population examined.^1-3 The prevalence increases substantially with age, affecting approximately 3% of people over 80 years of age.²

Venous leg ulcers (VLUs) arise from chronic venous insufficiency (CVI) and represent a significant healthcare burden. VLUs are associated with high recurrence rates, prolonged healing times, and decreased quality of life. For clinicians in wound care, understanding the pathophysiology, clinical features, and evidence-based treatments is essential to improve outcomes and prevent complications.

Etiology

VLUs can result from venous hypertension due to valvular incompetence, vein obstruction, or both.¹ This leads to inflammation, leukocyte activation, microcirculatory dysfunction, and increased matrix metalloproteinase (MMP) activity, which collectively impair wound healing. Both superficial and deep venous systems, and often perforating veins, are implicated. Genetic and metabolic factors may also contribute.

Risk Factors

VLUs are multifactorial in origin, with several risk factors predisposing individuals to their development:
Chronic venous insufficiency (CVI). VLUs primarily result from venous valve incompetence or obstruction.^2,3 Family history of CVI is a risk factor for VLUs.

Age. The incidence of VLUs increases significantly with age, particularly in those over 65.^2,3

History of deep vein thrombosis (DVT). DVT Leads to post-thrombotic syndrome and chronic venous hypertension.^2,3

Obesity. Increases venous pressure in the lower extremities.^2,3

Prolonged standing or sedentary lifestyle. Reduces calf muscle pump efficiency.^2,3

Pregnancy. Repeated pregnancies can weaken venous structures.^2,3

Clinical Presentation

VLUs typically are irregularly shaped with well-defined borders.^4,5 Symptoms may include heaviness in limbs, pruritus, and pain.⁶ Patients also report edema that gets worse throughout the day and improves when they elevate the limb.⁵ Physical examination may reveal signs of venous disease, such as varicose veins, edema, or venous dermatitis.⁴ 

VLUs may be located over bony prominences such as the gaiter area.⁴ Other findings include, telangiectasias, corona phlebectatica, atrophie blanche, lipodermatosclerosis, and inverted champagne-bottle deformity of the lower leg.^4,6

Diagnosis

Diagnosis is primarily clinical in nature, but should be confirmed and evaluated through additional modalities:

Duplex ultrasound. This is first-line imaging to assess for reflux and obstruction.¹ This can be ordered by the wound specialist or a patient may be a referred to a vascular specialists for this test or additional testing due to suspected need for venous intervention.

Ankle-brachial index (ABI). When appropriate, this can help to exclude significant arterial disease.¹ 

Wound biopsy. One may consider a biopsy for nonhealing VLUs or those with atypical features.¹

Laboratory testing. Perform a thrombophilia workup in select patients.¹ It may also be helpful to evaluate additional bloodwork to rule out any concerns that could contribute to or exacerbate lower extremity swelling such as kidney or cardiac etiologies.

Advanced imaging. Consider magnetic resonance venography (MRV), computed tomography venography (CTV), or intravascular ultrasound (IVUS) in suspected iliocaval obstruction.¹ 

Treatment

Treatment is multifactorial and evidence-based, emphasizing compression and local wound care:

Compression therapy. As the gold standard treatment, compression therapy contributes to improved healing and reduction of recurrence.¹ Multicomponent bandaging systems are preferrable over single-layer. Do not use compression if ABI <0.5.

Local wound care. Cleanse the wound with neutral, non-toxic solutions.¹ Surgical debridement is preferrable where possible; alternatives include enzymatic or biologic methods. Use dressings to maintain a moist wound bed and manage exudate. Foams and alginates are commonly used. For infection control, use systemic antibiotics only when clinical infection is evident; avoid routine, non-targeted use of topical antimicrobials. 

Pharmacologic therapy. Pentoxifylline and micronized purified flavonoid fraction (MPFF) may be choices for adjuncts to compression in certain cases.¹  

Advanced therapies. Consider biologic skin substitutes for nonhealing ulcers after 4–6 weeks of standard care.¹ Reserve skin grafting for large or recalcitrant ulcers.¹ Use negative pressure wound therapy (NPWT) as an adjunct treatment in specific cases.

Surgical and endovascular interventions. Possible options include ablation of incompetent superficial veins, perforator vein ablation if reflux persists, and Iliocaval stenting for proximal obstruction.¹

Complications

Without effective intervention, VLUs can result in a range of complications:

VLUs have high recurrence rates (50–70% at 6 months) if underlying venous pathology goes unaddressed. Other complications include infection in the form of cellulitis, osteomyelitis,and sepsis; chronic pain; and less frequently, skin cancer.¹

Malignant change, though rare, is an important complication to recognize, as tumors developing in the setting of chronic ulcers tend to be more aggressive. This malignant degeneration should be considered in ulcers that fail to heal or change character.⁷

References
1. O'Donnell TF Jr, Passman MA, Marston WA, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg. 2014;60(2 Suppl):3S-59S. doi:10.1016/j.jvs.2014.04.049
2. Bonkemeyer Millan S, Gan R, Townsend PE. Venous ulcers: diagnosis and treatment. Am Fam Physician. 2019;100(5):298-305.  
3. Robles-Tenorio A, Ocampo-Candiani J. Venous Leg Ulcer. [Updated 2022 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK567802/&nbsp;
4. Millan SB, Gan R, Townsend PE. Venous ulcers: diagnosis and treatment. Am Family Phys. 2019; 100(5):298-305. 
5. Lal BK. Venous ulcers of the lower extremity: definition, epidemiology, and economic and social burdens. Semin Vasc Surg. 2015;28(1):3-5. 
6. Vivas A, Lev-Tov H, Kirsner RS. Venous leg ulcers. Ann Intern Med. 2016;165(3):ITC17-ITC32. 
7. Collins L, Seraj S .Diagnosis and treatment of venous ulcers. Am Fam Physician. 2010. Apr 15;81(8):989-96