What’s in the blog?
- Why long-standing vein pressure breaks the skin down, and why it happens just above the ankle.
- What compression does, and the arterial check that comes before it.
- What treating the vein underneath changes, and when NICE advises referral.
Why the skin breaks down
A venous leg ulcer starts in the circulation rather than the skin. It is the visible end of a problem that has usually been building for years.
Veins in the leg carry blood upwards against gravity, and one-way valves stop it falling back. When those valves fail, blood pools in the lower leg and the pressure in the smallest vessels stays high all day instead of dropping when you walk. Over time that pressure damages the skin: fluid and blood cells leak out, the tissue becomes inflamed, and the skin around the ankle grows thin and fragile.
At that point it does not take much. A knock against a trolley, a scratch, a pulled plaster — and a wound opens that would have healed anywhere else on the body in a week, but here does not close at all.
Why it is almost always just above the ankle
Venous ulcers have a characteristic home: the inner side of the leg, a hand’s breadth above the ankle bone. That area is where venous pressure is highest when you are standing, and it is where the skin has usually been changing for some time before the ulcer appears — brown staining, hardening, or eczema.
An ulcer somewhere else on the leg, or one with a very different appearance, may not be venous at all, which is one of the reasons an ulcer is assessed rather than assumed to be venous.
Why dressings alone rarely finish the job
A dressing manages the surface of the wound. It does not change the pressure underneath that caused it, which is why an ulcer treated with dressings alone can stay open for months, close briefly, and open again in the same place.
It is perhaps the most useful thing to understand about venous ulcers: the wound is the symptom, and the vein is the cause.
What compression actually does
Compression bandaging or stockings apply graduated pressure — firmest at the ankle, easing further up — which supports the vein walls, helps blood move upwards and reduces the swelling that keeps the tissue starved. It is the mainstay of healing, and applied properly it works.
One important safety point. Compression is only appropriate once the arterial supply to the leg has been checked, usually by comparing blood pressure at the ankle with blood pressure in the arm. If the arteries are also narrowed, firm compression can do harm rather than good. Any proper assessment includes that check before compression is started, and it is a reasonable thing to ask about.
Treating the vein underneath
Alongside compression, a duplex ultrasound scan shows which veins are refluxing. Where a failing vein is found, treating it — with radiofrequency ablation or foam sclerotherapy, depending on the scan — addresses the pressure that caused the ulcer rather than only the wound it produced.
The practical argument for doing this is recurrence. An ulcer that heals under compression alone sits on a leg where nothing underneath has changed, and recurrence is common. Treating the vein reduces that risk considerably.
When to have it looked at
NICE guidance is clear that a break in the skin below the knee that has not healed within two weeks is a reason for referral to a vascular service, as is a venous leg ulcer that has healed. Two weeks is a short window, and deliberately so.
If you have had a leg ulcer managed with dressings for months without a duplex scan, that is worth raising — with your GP, or directly, if you would rather have it assessed privately.
Speak to Mr Sidloff
If any of this sounds like your symptoms, an initial consultation includes a duplex ultrasound scan where it is needed, and a treatment plan based on what the scan shows. Appointments are usually available within five days.