What are the 10 most important
steps in leg ulcer management?

Leg ulcers should be cleaned using room temperature water or saline solution.

Compression bandaging is the most effective treatment for leg ulcers. Compression bandaging works by helping to push the blood in the leg veins back up to the heart. A healthcare professional will determine the appropriate strength of the bandage for the patient. Once a holistic assessment has been carried out, the strongest bandage a patient can tolerate should be applied.

Compression bandaging is a skilled procedure that should only be undertaken by a healthcare professional.

It is recommended that patients continue with some form of compression therapy after a leg ulcer has healed to prevent the development of another ulcer in the future.

Hosiery is not recommended as the first line of treatment for leg ulcers. However, specialist hosiery, such as compression socks, can be effective in both the prevention and treatment of leg ulcers. Compression hosiery is designed to improve circulation and encourage blood flow upwards towards the heart.

Compression therapy is the cornerstone of effective leg ulcer treatment. However, selecting the appropriate primary wound dressings can help with symptom control and optimise the local wound environment to promote healing. A healthcare professional should conduct an assessment that considers the stage of wound healing, the amount of exudate, infection, odour, adhesives, absorption, pain during dressing changes, periwound skin, and patient preference when choosing the appropriate leg ulcer dressings.

Research indicates that only around 50% of leg ulcers heal after 26 weeks. As leg ulcers can lead to a continuous build-up of necrotic and devitalised tissue, debridement is often required to maintain healthy tissue and promote healing.[1]

The management of a patient’s skin is an integral aspect of leg ulcer treatment. As leg ulcers predominantly affect the elderly population, skin integrity is usually already compromised by the ageing process. This can result in dry, flaky, and itchy skin, which can make the leg ulcer healing process more uncomfortable. This can be treated with fragrance-free emollients once or twice a day, depending on the condition of the patient’s skin. Emollients containing urea are advised.[2]

Ensuring adequate lubrication of the skin and any compression bandaging can reduce venous hypertension, which is associated with the development of eczema in leg ulcer patients.[3]

Antimicrobial emollients are recommended if there are any signs of infection around the wound bed.[4]

Skin irritation (dermatitis) near the leg ulcer can be caused by various factors, including leaky veins, dressings, bandages, and certain creams. If this does occur, the patient should be referred to a dermatologist to conduct skin patch tests.[5]

Systemic therapies can be used together with compression therapy at the healthcare professional’s discretion.

Antibiotics can be used when the presence of an infection is confirmed.[6]

Analgesia or local anaesthetic cream may be required to minimise pain during debridement.

If the patient is experiencing ongoing pain that is affecting their quality of life, a healthcare professional should evaluate what pain medication, if any, is most appropriate.

Leg ulcers are often accompanied by swelling in the lower legs and ankles. This type of swelling is known as oedema, and it is caused by fluid (i.e., blood) pooling in the lower limbs.

Elevation above the heart level is a strategy that can relieve oedema by promoting more effective capillary and lymphatic function. Ensuring that a patient’s limb remains elevated whenever possible will allow the accumulated fluid to drain away from the legs. 

Although it is important to maintain regular sleeping habits, such as sleeping in a bed rather than a chair, a healthcare professional may recommend the patient keep their feet elevated at night. This may be done with a certified circulation booster device or a set of pillows.

The periwound is defined as the skin within four centimetres of the wound bed edge. Protecting the periwound area is important for promoting optimal leg ulcer healing and ensuring better patient outcomes. Leg ulcers usually entail the risk of exudate-induced maceration. A healthcare professional will assess which dressings (i.e., primary wound contact layers) and topical ointments (i.e., acrylate terpolymer) should be used to maintain moisture balance and prevent compromising the integrity of the surrounding skin.

Ensuring that the patient remains as mobile and active as possible is fundamental to effective leg ulcer management. Exercise, in conjunction with compression, is effective in improving calf muscle pump function. Exercise can increase circulation, which helps leg ulcers heal more effectively by preventing blood from accumulating in the lower legs and causing swelling.

Patients with leg ulcers sometimes experience mobility issues. This means that light exercise, including leisurely walks, can be quite helpful for maintaining circulation.

Where possible, the patient should avoid standing still for prolonged periods. However, if this is unavoidable, the patient should be encouraged to exercise on the spot by moving their toes inside their shoes.

If the patient is sitting, they can exercise by rotating their ankles and bending their toes away from themselves and back. 

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