Venous Ulcer: Modern Treatment and Permanent Wound Closure

A venous leg ulcer is an open wound on the lower leg or ankle that develops as the end-stage complication of chronic venous insufficiency (CVI). It is the most severe manifestation of varicose vein disease, affecting approximately 1% of the adult population and up to 3.5% of those over 65. These wounds are painful, slow to heal, prone to infection, and devastatingly impact quality of life — with many patients living with open wounds for months or years. The key insight of modern vascular medicine is that venous ulcers cannot be permanently healed by wound dressings alone: the underlying venous reflux must be corrected.

Why Do Venous Ulcers Develop?

The pathway from varicose veins to leg ulcer typically unfolds over years:

1. Venous reflux: Incompetent valves in the great saphenous vein or perforator veins allow blood to flow backwards and pool in the leg
2. Venous hypertension: Chronically elevated venous pressure in the lower leg damages the capillary walls, causing protein and red blood cells to leak into surrounding tissue
3. Lipodermatosclerosis: The leaked red blood cells deposit hemosiderin (brown pigment), and the skin becomes hardened, discoloured, and chronically inflamed — the "inverted champagne bottle" appearance of the lower leg
4. Ulceration: Even minor trauma to the damaged skin causes a wound that, without adequate venous pressure reduction, cannot heal

Distinguishing Venous Ulcers from Other Leg Wounds

Correct identification is essential because treatment differs fundamentally:

• Location: Venous ulcers typically occur around the medial (inner) ankle — the gaiter area. Arterial ulcers occur on the foot, toes, and pressure points. Diabetic ulcers occur on the sole under pressure points.
• Appearance: Shallow, irregular border, weeping, surrounded by lipodermatosclerosis and hemosiderin staining
• Pain: Varies — some venous ulcers are surprisingly painless; others are severely painful. Pain typically worsens with leg dependency and improves with elevation.
• Pulses: Foot pulses are present in pure venous ulcers. Absent pulses suggest arterial disease requiring ABI measurement before compression is applied.

The Modern Treatment Protocol

Successful venous ulcer management requires treating both the wound surface and the underlying cause simultaneously:

1. Venous duplex assessment: Identifies which veins are refluxing — this guides the interventional plan
2. Compression therapy: Four-layer bandaging (in the clinic) or high-grade compression stockings (for maintenance) — the pressure gradient reduces venous hypertension and promotes healing. Healing rates with compression alone are approximately 50–70% at 12 weeks.
3. Wound bed preparation: Debridement of slough, appropriate moist wound dressings matched to the wound's exudate level and infection status
4. Treating the reflux: The EVRA trial (2019) demonstrated that early endovenous ablation (laser or radiofrequency) of the refluxing saphenous vein, performed alongside compression, heals venous ulcers significantly faster than compression alone and dramatically reduces recurrence rates. This is the current standard of care.
5. Infection management: Swab-guided antibiotics when clinical infection is present; routine antibiotics are not beneficial for non-infected wounds
6. Nutrition optimisation: Adequate protein, vitamin C, and zinc are essential for wound healing
7. Lifelong compression after healing: Without continued compression stocking use, 50–70% of venous ulcers recur within 5 years