Varicose Ulcer (Venous Leg Ulcer)

Terminology note: The term "varicose ulcer" is a misnomer. These ulcers are more precisely called venous ulcers or venous leg ulcers. They are not caused by varicose veins per se, but are a complication of deep vein thrombosis and chronic venous insufficiency. Their association with varicose veins in the upper part of the limb led to the popular but inaccurate label.

• S Das: A Manual on Clinical Surgery, 13th Ed

Definition

• Venous disease accounts for ~85% of all chronic lower limb ulcers in resource-rich countries
• Community prevalence: 0.1-0.3% in adults, rising to 2-4% in the elderly
• Dressings alone account for 1-3% of western healthcare expenditure
• 15-30% of "venous" ulcers have concomitant arterial disease ("mixed" ulcers)

Pathophysiology

• Primary valve incompetence of the saphenous veins
• Incompetence of the perforating veins (especially Cockett perforators)
• Incompetence or obstruction of the deep veins (post-thrombotic)

CEAP Clinical Classification

Clinical Features

Site

• Characteristically in the "gaiter region" - the skin between the calf muscles and the ankle
• Medial aspect of the lower third of the leg, typically above the medial malleolus (where Cockett perforators join the posterior tibial vein to the posterior arch vein)
• Ulcers on the foot or upper calf should prompt consideration of other diagnoses

Features of the Ulcer

Surrounding Changes

• Haemosiderin pigmentation (brown discolouration from haemosiderin and melanin) - almost universal
• Lipodermatosclerosis (LDS): thickening, induration, inflammation and fibrosis of calf skin in chronic cases
• Varicose eczema (stasis dermatitis)
• Itching often precedes ulcer development (possibly from mast cell degranulation)

Comparison with Other Lower Limb Ulcers

Investigation

1. Duplex ultrasound (DUS) - gold standard; identifies reflux in superficial, deep, and perforating veins. Presence of reflux supports the diagnosis and guides treatment.
2. ABPI (Ankle-Brachial Pressure Index) - essential to exclude arterial disease and guide compression therapy:
   • ABPI >0.8: Full compression (35-40 mmHg)
   • ABPI 0.5-0.8: Modified compression (30 mmHg) - safe with monitoring
   • ABPI <0.5 or ankle pressure <60 mmHg: Revascularisation required before compression
3. Ambulatory Venous Pressure (AVP): >80 mmHg = 80% incidence of venous ulceration
4. Biopsy - mandatory if ulcer edge is raised/elevated (to exclude Marjolin's ulcer - squamous cell carcinoma arising in chronic venous ulcer)
5. Photoplethysmography / Air plethysmography - assess venous return time and calf pump function

Management

1. Compression Therapy (Mainstay)

• Most clinically and cost-effective approach
• Four-layer compression bandaging (most effective):
  1. Orthopaedic wool - distributes pressure, absorbs exudate
  2. Cotton crepe - smooths wool, holds in place
  3. Elastic bandage - first compressive layer (~1/3 of interface pressure)
  4. Cohesive bandage - second compressive layer (~2/3 of interface pressure)
• Target interface pressure: 35-40 mmHg in pure venous ulcers
• Two-layer compression hosiery is an alternative

2. Superficial Venous Ablation / Surgery

• Endovenous ablation (laser, radiofrequency) of superficial reflux:
  • Accelerates healing and reduces recurrence
  • ESCHAR trial (UK, RCT): Superficial venous surgery + compression vs compression alone - surgery had no additive effect on ulcer healing but significantly reduced recurrence at 4 years
  • Early endovenous ablation almost halves time to healing and is cost-effective

3. SEPS (Subfascial Endoscopic Perforator Surgery)

• Interrupts incompetent Cockett perforators via endoscope
• Healing achieved in ~88% of ulcers at 1 year in registry data
• Efficacy as standalone procedure is controversial; largely replaced by ultrasound-guided sclerotherapy

4. Wound Care

• Primary dressings: no single dressing has been shown superior
• Debridement of slough
• Topical antibiotics do not speed healing in the absence of cellulitis
• Skin grafting: Pinch grafts or excision with mesh grafting - good early healing, ~50% healed at 5 years

5. Adjuncts

• Pentoxifylline - improves microvascular perfusion (reduces plasma viscosity, cytokine inhibition); useful adjunct to compression
• Horse chestnut seed extract - safe for chronic venous hypertension
• Platelet-rich plasma (PRP) - recent 2026 meta-analysis (PMID: 41643347) supports its use
• Photobiomodulation - a 2026 systematic review (PMID: 41889013) shows benefit for venous leg ulcer healing
• Biological dressings (fetal keratinocytes, collagen meshes) improve healing but are not cost-effective for most cases

Prevention of Recurrence

• Treat superficial venous incompetence if not already done
• Class 2 below-knee graduated compression stockings for life in patients with:
  • Residual deep venous reflux or occlusion
  • Recurrent ulceration
• Compliance with compression stockings is the single most important factor - up to 50% recur in their lifetime, primarily due to non-compliance

Prognosis

• Nearly all venous ulcers can be healed with correct treatment
• 20-30% reulceration rate at 5 years even with successful ablation or diligent stocking use
• Highest risk group: post-thrombotic limb
• Venous ulcers are characteristically difficult to heal and prone to recurrence

Complication: Marjolin's Ulcer