Venous Leg Ulcers: Causes, Treatments & Prevention

Citable definition: A venous leg ulcer (VLU) is a chronic, open wound of the lower leg caused by sustained venous hypertension (abnormally elevated blood pressure in the leg veins), representing the most severe complication of chronic venous insufficiency (CVI) and classified as CEAP stage C6 in the international venous classification system (Bonkemeyer Millan S et al., American Family Physician, 2019; PMID: 31478635).

What Is a Venous Leg Ulcer?

Venous leg ulcers are the most serious manifestation of chronic venous insufficiency (CVI) — a condition in which the one-way valves inside the leg veins fail to work properly, allowing blood to pool in the lower limbs instead of returning efficiently to the heart.

Over time, this pooling raises pressure within the small veins and capillaries of the skin. The resulting venous hypertension triggers a cascade of changes: inflammation, leakage of proteins and red blood cells into surrounding tissue, progressive skin hardening known as lipodermatosclerosis (a fibrous thickening of the skin and fat layer), and ultimately skin breakdown and ulceration (Bonkemeyer Millan S et al., Am Fam Physician, 2019; PMID: 31478635).

VLUs account for the vast majority of all chronic leg ulcers and are estimated to affect 1% to 3% of the adult population in the United States (Bonkemeyer Millan S et al., Am Fam Physician, 2019; PMID: 31478635). The burden is not merely physical: a 2018 UK real-world study documented the substantial financial cost of managing VLUs in routine clinical practice, underscoring the need for structured, multidisciplinary care pathways (Guest JF et al., International Wound Journal, 2018; PMID: 29243398).

Risk factors include advanced age, obesity, a history of deep vein thrombosis (DVT — a blood clot in the deep veins), varicose veins, prolonged standing, and previous leg injuries.

Symptoms

Venous leg ulcers rarely appear without warning. They typically develop against a background of longstanding venous disease. Recognizing the earlier signs can help prevent full ulceration.

Common warning signs (in approximate order of frequency):

• Ankle swelling (edema): Often worse at the end of the day or after prolonged standing
• Skin discoloration: A brownish or reddish tinge around the lower leg and ankle, caused by hemosiderin (iron pigment from leaked red blood cells) depositing in the skin
• Skin thickening and hardening: Lipodermatosclerosis gives the lower leg a woody, tight feel
• Varicose veins or prominent surface veins
• Itching, aching, or heaviness in the legs
• Atrophie blanche (small white scars surrounded by dilated capillaries, a sign of advanced skin damage)
• Open wound: Usually located in the “gaiter area” (the region between the ankle and mid-calf), shallow, with irregular borders and a moist, sometimes weeping wound bed

Pain levels vary considerably. Some patients report significant discomfort, particularly at night; others experience surprisingly little pain. Infected ulcers may produce increased exudate (wound fluid), odor, surrounding redness, and warmth (Franks PJ et al., Journal of Wound Care, 2016; PMID: 27292202).

Diagnosis

Diagnosis of a venous leg ulcer is primarily clinical — based on history, wound appearance, and location — but several investigations are essential before treatment begins.

1. ABPI (Ankle-Brachial Pressure Index): This simple, non-invasive bedside test compares blood pressure at the ankle with that at the arm using a Doppler ultrasound probe. It is mandatory before applying compression therapy to rule out significant arterial disease (peripheral artery disease — PAD), which would make strong compression dangerous. An ABPI of 0.8 or above generally indicates that compression is safe (Bonkemeyer Millan S et al., Am Fam Physician, 2019; PMID: 31478635).

2. Duplex ultrasound: This imaging technique combines standard ultrasound with Doppler flow measurement to map the venous system of the leg, identify reflux (backward flow through faulty valves), and detect any residual deep vein obstruction. It is the cornerstone of venous investigation and guides decisions about endovenous treatment.

3. Wound assessment: Clinicians evaluate wound size, depth, tissue type (granulation, slough, necrosis), exudate level, and signs of infection. Wound culture may be taken if infection is suspected.

4. Pelvic venous disease: In women with recurrent or atypical ulcers, pelvic venous disease (abnormal veins arising from the pelvis) should be considered and investigated with dedicated imaging, as recommended by the 2022 ESVS (European Society for Vascular Surgery) guidelines on pelvic venous disorders.

Treatment

The Pillars of Venous Leg Ulcer Management

Treatment of VLUs is multifaceted and should be tailored to each patient. The following table summarizes the main approaches, from conservative to interventional.

1. Compression Therapy: The Cornerstone

Compression therapy — the application of controlled external pressure to the leg to counteract venous hypertension — remains the single most important treatment for VLUs, with the strongest evidence base of any intervention. A landmark Cochrane meta-analysis (2021; PMID: 34308565) demonstrated unequivocally that compression is superior to no compression for healing venous leg ulcers.

However, compression is not a static prescription. A 2026 study published in the International Wound Journal examined how the pressure and stiffness of compression systems change over time during wear, highlighting the importance of monitoring and adjusting compression parameters to maintain clinical effectiveness — a finding with direct implications for how clinicians optimize compression regimens in practice (García JFJ et al., Int Wound J, 2026; PMID: 41840919).

Adherence remains a significant challenge. Patients often struggle with applying and removing compression garments, particularly those with reduced hand strength or limited mobility (Franks PJ et al., J Wound Care, 2016; PMID: 27292202). Both ESVS and AHA/ACC-aligned guidelines emphasize patient education and the selection of compression systems that patients can realistically use.

2. Wound Dressings and Local Wound Care

Appropriate wound dressings create an optimal moist healing environment, manage exudate, and protect the wound from infection. Options include foam dressings, hydrocolloids, alginates, hydrogels, and antimicrobial dressings containing silver or iodine.

Despite the wide variety available, a 2022 Cochrane review on hydrogel dressings (PMID: 35930364) found insufficient evidence to conclude that any one dressing type is superior to others for healing VLUs. The choice should therefore be guided by wound characteristics, patient comfort, and cost-effectiveness.

A 2026 multicentre cohort study published in Cureus compared several topical treatment strategies for chronic leg ulcers, contributing valuable real-world comparative data to guide clinical decision-making (Fakhry A et al., Cureus, 2026; PMID: 41948276).

3. Endovenous Ablation: Treating the Root Cause

Addressing the underlying venous insufficiency — not just the wound itself — is now firmly established as best practice. A 2023 Cochrane meta-analysis (PMID: 37497816) confirmed that endovenous ablation (minimally invasive techniques such as laser or radiofrequency that close the faulty superficial veins from the inside) improves healing rates and reduces recurrence compared with compression alone.

Both the SVS/AVF (Society for Vascular Surgery / American Venous Forum) and ESVS guidelines recommend early treatment of superficial venous insufficiency in patients with active or healed VLUs. This approach treats the hemodynamic (blood flow) cause of the ulcer, not just its surface manifestation.

4. Emerging and Adjunctive Therapies

Several innovative treatments are under active investigation for patients whose ulcers do not respond to standard care:

• Platelet-rich fibrin (PRF): A 2026 randomized controlled trial (Phlebology; PMID: 41816977) evaluated autologous PRF — a concentrate derived from the patient’s own blood containing growth factors — compared with normal saline in chronic VLUs, with promising preliminary results. Larger trials are needed before this can be recommended routinely.

• Photobiomodulation (low-level light therapy): A 2026 systematic review and meta-analysis (Wound Repair and Regeneration; PMID: 41889013) examined the effect of light-based therapy on VLU healing, finding a signal of benefit. Evidence quality remains moderate and further research is required.

• Topical oxygen therapy: A 2026 case series published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders reported encouraging outcomes with topical oxygen therapy in refractory (treatment-resistant) venous ulcers (Williams ZE et al., J Vasc Surg Venous Lymphat Disord, 2026; PMID: 41864536). This technique delivers concentrated oxygen directly to the wound surface to support tissue repair.

These therapies represent a rapidly evolving frontier. Consult your physician or vascular specialist to discuss whether any may be appropriate in your individual case.

Prevention

Preventing a first ulcer — or a recurrence after healing — requires consistent attention to venous health:

1. Wear compression hosiery daily. Even after an ulcer heals, lifelong compression is the most effective way to prevent recurrence. Work with your healthcare team to find a garment you can apply independently.
2. Elevate your legs. Aim to raise your legs above heart level for 30 minutes, three to four times daily, to reduce venous pressure.
3. Stay physically active. Walking activates the calf muscle pump — the body’s natural mechanism for pushing venous blood upward. Even short, regular walks make a difference.
4. Maintain a healthy weight. Obesity significantly increases venous pressure in the legs.
5. Avoid prolonged standing or sitting. If your work requires it, take regular movement breaks and perform ankle flexion exercises.
6. Protect your skin. Keep the lower leg skin moisturized to prevent dryness and cracking, which can be entry points for infection.
7. Attend follow-up appointments. Early detection of skin changes (discoloration, thickening) allows intervention before ulceration occurs.

Explore more evidence-based strategies on our prevention pages.

When to See a Doctor

Seek prompt medical attention — from your family physician or a vascular specialist — if you notice:

• Any open wound or sore on your lower leg that does not begin to heal within 2 weeks
• Increasing pain, warmth, swelling, or redness around an existing wound (possible signs of infection or cellulitis)
• Fever or chills in combination with a leg wound
• Rapidly enlarging wound area
• A wound that has been present for more than 4–6 weeks without improvement despite self-care
• Any new or worsening leg swelling, particularly after a period of immobility (which may suggest DVT)

Do not attempt to self-treat a venous leg ulcer. Inappropriate dressings, missed arterial disease, or delayed treatment can significantly worsen outcomes. Early specialist involvement — including duplex ultrasound and ABPI measurement — is essential.

Also available in French

Sources

1. Bonkemeyer Millan S, Gan R, Townsend PE. Venous Ulcers: Diagnosis and Treatment. Am Fam Physician. 2019;100(5):298–305. PMID: 31478635

2. Franks PJ, Barker J, Collier M, et al. Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice. J Wound Care. 2016;25 Suppl 6:S1–S67. DOI: 10.12968/jowc.2016.25.Sup6.S1. PMID: 27292202

3. Guest JF, Fuller GW, Vowden P. Venous leg ulcer management in clinical practice in the UK: costs and outcomes. Int Wound J. 2018;15(1):29–37. DOI: 10.1111/iwj.12814. PMID: 29243398

4. García JFJ et al. Temporal Assessment of Pressure and Stiffness in Compression Therapy for Venous Leg Ulcers: Implications for Clinical Optimization. Int Wound J. 2026;23(3):e70868. DOI: 10.1111/iwj.70868. PMID: 41840919

5. Fakhry A et al. A Comparative Study of Topical Treatments for the Management of Chronic Leg Ulcers in a Multi-Center Cohort. Cureus. 2026;18(3):e104830. DOI: 10.7759/cureus.104830. PMID: 41948276

6. Jyothirmai P et al. Efficacy of autologous platelet-rich fibrin compared to normal saline in the management of chronic venous leg ulcers: A randomized controlled trial. Phlebology. 2026. DOI: 10.1177/02683555261433271. PMID: 41816977

7. Williams ZE, Singh I, Marks N, Ascher E, Hingorani AP. Innovative wound management of refractory venous ulcers with topical oxygen therapy. J Vasc Surg Venous Lymphat Disord. 2026. DOI: 10.1016/j.jvsv.2026.102487. PMID: 41864536

8. The Healing Effect of Photobiomodulation on Venous Leg Ulcers: A Systematic Review and Meta-Analysis. Wound Repair Regen. 2026;34(2):e70144. DOI: 10.1111/wrr.70144. PMID: 41889013

9. Cochrane Review on compression for venous leg ulcers (2021). PMID: 34308565

10. Cochrane Review on endovenous ablation for venous leg ulcers (2023). PMID: 37497816

11. Cochrane Review on hydrogel dressings for venous leg ulcers (2022). PMID: 35930364

Medical Disclaimer: This article is produced by the Petit Veinard Editorial Board for informational and educational purposes only. It does not constitute medical advice, diagnosis, or a treatment recommendation. All content is based on published scientific literature and established clinical guidelines at the time of writing. Individual medical situations vary — always consult a qualified physician or vascular specialist before making any decision about your health or treatment. In case of a medical emergency, contact your local emergency services immediately.