Presentation and Clinical Diagnosis

There are some classical signs to look for when assessing a leg wound that will indicate that the patient may have a venous ulcer. These include:

Oedema

Prolonged periods of time with legs down (e.g. sitting, standing) as opposed to elevated, along with immobility, all contribute to leg oedema (NICE, 2015).

Increased pressures in the capillaries become torturous and dilated and eventually fail. This allows fluid to leak into subcutaneous cells and interstitial spaces, causing oedema. This can cause the patient to experience discomfort when their limb is elevated.

Oedema that has been present for longer than three months and is not resolved by elevation, bedrest or diuretics is known as chronic oedema (Wounds UK, 2015). If left untreated, chronic oedema can lead to failure of the lymphatic system and, in turn, localised fluid retention and tissue swelling, known as lymphoedema (Lymphoedema Framework, 2006, 2021).

Pain

Between 17% and 65% of people with a leg ulcer experience severe or continuous pain with a major impact on quality of life (Briggs & Nelson, 2010). Worsening pain may indicate poor ulcer healing, arterial disease, diabetic neuropathy or cellulitis (NICE, 2015).

Staining of skin

Haemosiderin staining is dark brown or rusty discolouration of the lower legs caused by chronic venous disease (Bjork, 2013). This usually occurs in the gaiter area (the lower half of the leg above and around the ankle).

Distension of the capillaries allows red blood cells (RBCs) to escape into the extravascular space. Haemoglobin is then released from RBCs and broken down, causing brown staining. Eventually, lipodermatosclerosis develops as the underlying tissues become fibrosed. This gives the leg a woody (indurated) texture/feel and can give the leg a characteristic champagne bottle shape.

Varicose/venous eczema

This occurs due to venous stasis, which allows a build-up of deoxygenated blood and irritants in the dermal cells. Venous eczema is an inflammatory condition characterised by red, itchy, scaly, or flaky skin, which may have blisters and crusts on the surface (NICE, 2020).

Ankle flare

This is caused by distension of the tiny veins on the medial aspect of the foot. It is noticeable on the lateral aspect of the ankle.

Atrophie blanche

This is a particular type of angular scar occurring on the lower leg or foot, usually after a skin injury, where the blood supply is poor, and healing is delayed.

Atrophie blanche is caused by distension of the tiny veins on the medial aspect of the foot, susceptible to trauma. Venous congestion causes the capillaries to become swollen and congested. It is sometimes visible as tiny red “dots” under the skin. Where the capillaries cannot sustain the pressure, they atrophy, leaving white “lacy” areas of avascular tissue. (DermaNet NZ, 2017)