Arterial leg ulcer: causes, symptoms and treatment

The NHS describes a leg ulcer as a long-lasting sore that takes more than 2 weeks to heal. Several types exist. Venous leg ulcers are the most common, accounting for more than 60 per cent of all cases, while arterial leg ulcers are caused by poor blood circulation in the arteries. The NHS also lists diabetic, vasculitic, traumatic and malignant leg ulcers.

In an arterial ulcer, the problem is that not enough oxygen-rich blood reaches the skin and tissues. The NHS says most ulcers caused by artery disease or diabetes occur on the foot rather than the leg, so a wound on the toes, heel or foot that is not healing should be taken seriously. Because it is a blood supply problem, healing depends on dealing with the circulation as well as the wound.

Arterial ulcers are linked to peripheral arterial disease (PAD). The NHS explains that PAD is usually caused by a build-up of fatty deposits made of cholesterol and other waste substances in the walls of the leg arteries. This makes the arteries narrower and restricts blood flow to the legs, a process called atherosclerosis.

The NHS lists smoking as the most significant risk factor, along with type 1 and type 2 diabetes, high blood pressure, high cholesterol and growing older. Having PAD also makes other forms of cardiovascular disease more likely, such as coronary heart disease, stroke, heart attack and angina, because the same process affects arteries elsewhere.

Many people with PAD have no symptoms, but the NHS describes common ones, and an ulcer is a sign that the circulation is badly affected. The symptoms often develop slowly. If symptoms develop quickly or suddenly get worse, the NHS says this could be a sign of a serious problem requiring immediate treatment.

• A painful ache in the legs when walking that goes away after a few minutes of rest (intermittent claudication).

• Ulcers on the feet and legs that do not heal.

• Hair loss on the legs and feet, and brittle, slow-growing toenails.

• Numbness or weakness in the legs and the muscles in the legs shrinking.

• Skin turning paler than usual or blue, or shiny skin; this may be harder to see on brown and black skin.

The NHS describes critical limb ischaemia (CLI) as an extremely serious complication that develops when blood flow to the legs becomes severely restricted. Its symptoms include a severe burning pain in the legs and feet that continues even at rest, pale, shiny, smooth and dry skin, wounds and ulcers that do not heal, loss of muscle mass, and skin on the toes or lower limbs that becomes cold and numb, turns red then black or swells and produces smelly pus, which is gangrene.

If you think you are developing symptoms of CLI, the NHS says to contact a GP immediately and, if that is not possible, to call 111 or use 111 online. An angioplasty or bypass graft is usually recommended for CLI, although these may not always be successful or possible, and in a few cases an amputation may be required.

The NHS says you should see a GP if you think you have a leg ulcer, as it needs specialist treatment to help it heal, and that the GP will examine your leg and may do additional tests to rule out other conditions. Because the type of ulcer determines the treatment, identifying whether the cause is venous, arterial, diabetic or something else is the first step.

PAD is usually diagnosed through a physical examination by a GP and by comparing the blood pressure in the arm and the ankle. A difference between the two may indicate PAD and is called the ankle brachial pressure index (ABPI). Further scans or specialist vascular assessment may follow if the picture is unclear or if the leg is severely affected.

The NHS says there is no cure for PAD, but lifestyle changes and medicine can help reduce symptoms and the risk of other cardiovascular disease, and that surgery may be used in severe cases or when initial treatment has not reduced symptoms. The two most important lifestyle changes are exercising more regularly and stopping smoking.

Medicines include statins if LDL cholesterol is high, antihypertensives for high blood pressure, and medicines that reduce the risk of blood clots, such as low-dose aspirin, clopidogrel or rivaroxaban. Poorly controlled diabetes can make PAD symptoms worse, so managing diabetes properly is part of treatment. The NHS also notes that NICE recommends supervised exercise as one of the first steps, usually 2 hours a week for 3 months.

Revascularisation, a procedure to restore blood flow, may be recommended when symptoms are severe or have not responded. The NHS describes angioplasty, where a narrowed artery is widened with a balloon, and artery bypass graft, where blood vessels from another part of the body bypass a blockage. A team of specialist surgeons, doctors and nurses discusses the options and risks with you.

The NHS notes for venous ulcers that treatment includes cleaning and dressing the wound and using compression to improve the flow of blood in the legs, which is why the type of ulcer must be established first, and that antibiotics may be used if an ulcer becomes infected but do not help ulcers heal.

The NHS says that with treatment most people's PAD symptoms remain stable and some may notice an improvement in their pain, but that if treatment is unsuccessful there is a risk of potentially serious complications. Looking after the feet, avoiding injury and getting any new wound checked promptly are part of daily life.

The NHS also acknowledges that PAD can cause severe pain and disrupt life, and that if you are dealing with depression or anxiety it is important to access support to look after your mental wellbeing. Eating a balanced diet, managing your weight and cutting down on alcohol are among other changes that reduce the risk of further cardiovascular disease.

On the NHS, a leg ulcer is assessed by a GP or practice nurse and may be managed in a community leg ulcer or tissue viability service, with referral to a vascular team if arterial disease is suspected or the limb is threatened.

Some people also see a private vascular surgeon for faster assessment or a second opinion. The tests and procedures are the same, and the main differences are waiting time and choice of surgeon. Tell any clinician about smoking, diabetes and medicines, and take along any previous scan results.