For length, the longest distance is measured top to bottom regardless of orientation. Width is the longest distance side to side perpendicular to the length. To measure depth, a cotton-tipped swab is inserted into the deepest portion of the wound. The swab is grasped by its handle flush with the wound margins and is removed. The distance between the tip of the swab and the fingers is then measured. This technique may also be used to measure tunneling and undermining.

The etiology of the ulcer can often be determined by clinical assessment alone. Additional tests, such as ultrasound, arterial and venous duplex, and ankle-brachial indices (ABI) are useful in selected cases. ABI is calculated by dividing the ankle systolic pressure by the higher of the two systolic pressures obtained from the brachial arteries in both arms. Normally the ankle pressure should be equal to the arm pressure. ABIs in diabetics or in those with calcified vessels can be falsely elevated. Laboratory investigations may also be indicated by assessment and include: complete blood count and differential, fasting glucose and lipids, serum albumin, ferritin and zinc, inflammatory markers, hypercoagulability screen, rheumatoid factor, cryoglobulins, and hepatitis screen. Specimens for cultures should be obtained by biopsy or following wound debridement to aid differentiation between colonization and infection. When the diagnosis is still unclear or the ulcer is unresponsive to therapy, a biopsy and fungal and mycobacterial cultures should be considered to rule out other causes of chronic leg ulcers. Either multiple sampling biopsies or preferably a deep-wedge biopsy including the ulcer bed and edge are required for histopathology. Patch testing may be considered if a contact allergic component is suspected and plain film, blood cultures +/- more specific investigations if an underlying osteomyelitis is suspected.

Treatment of leg ulcers is dependent on identifying and treating the cause and exacerbating factors and meticulous wound care (Appendix B). Management of leg ulcers can be difficult and requires significant dedication from the patient and the provider. Healing is evidenced by a decrease in ulcer dimensions, an increase in granulation tissue, and re-epithelialization. An approach to a chronic wound or skin ulceration is presented in Figure 20-1. Specific dressing types and examples are mentioned in Figure 20-1 as well as in more detail in Table 20-2.

For most wounds, an occlusive dressing will maintain adequate moisture and may permit a patient to have a dressing on for more than 24 hours. The interval in dressing changes depends on the type and quality of the wound. There are five main types of dressing available (Table 20-2) (Figs. 20-2 to 20-6).

Maintaining a clean wound is essential for the healing process. Depending on the wound, this can be accomplished by mild soap and water or with saline.


This should be performed on a regular basis to ensure that the wound continues to be clean. Depending on the patient and the location of the wound, patients may need assistance with this. If patients develop an infection, this will increase healing time for the wound and may lead to cellulitis, sepsis, osteomyelitis, or other complications. Usage of hydrogen peroxide solution, povidone iodine, or acetic acid solutions is contraindicated, as they are cytotoxic to migrating/dividing keratinocytes in the wound base.

Wounds re-epithelialize more rapidly when the wound bed is kept moist (not wet) due to enhanced keratinocyte migration. Moist wounds can be maintained with topical ointments such as white petrolatum. Many patients will heal only
using white petrolatum. An antibacterial ointment is not necessary in most cases. Some patients may need topical antibiotics due to infection; however a few may become sensitized to these products or other preservatives in topical medicaments. This leads to an allergic contact dermatitis and complicates the healing process. Also, allergy to topical antibiotics such as neomycin or bacitracin may develop in chronic ulcer patients. In addition to topical ointments, dressings are essential to maintaining a moist wound.

The first consideration in healing an ulcer is to assess the nutritional status of the patient. A malnourished and/or vitamin-deficient patient will heal more slowly. Assessing levels of vitamin A, C, E, and zinc as well as a prealbumin level are helpful. Keeping the tissue nourished is challenging for many ulcer patients. Essentially, this means increasing the oxygen available to the wound base through improved blood flow or by adding pressure on the leg to decrease edema and improve venous flow. For arterial ulcers, vascular bypass may be necessary to heal recalcitrant ulcerations.

Skin ulcerations caused by venous insufficiency are common in the general population and are the most commonly encountered leg ulceration. The overall prevalence of vascular ulcers is not known, but it is estimated at ∼1% of the population. Eighty percent of these ulcers are thought to be venous ulcers with the remaining 20% being arterial or mixed venous and arterial in nature.

Venous ulcers are associated with chronic venous insufficiency. Normally during exercise, leg muscle contraction increases venous return and decreases venous pressure in the legs. In patients with incompetent venous valves, venous pressure remains high despite exercise and muscle contraction. Though the pathophysiology of venous ulceration is not fully elucidated, it is known to be related to multiple predisposing factors, presented in Table 20-3. These elements may contribute to incompetence of the perforating and deep vein valves or calf muscle pump dysfunction. Venous hypertension results in inflammation leading to capillary damage, capillary leakage, and edema.

With chronic venous hypertension, multiple cytokines and fibrinogen are released leading to more inflammation. In time, remodeling leads to capillary proliferation and a fibrous fibrinogen cuff in the vessel, impeding oxygen delivery. Alternately, some believe that ulcerations are caused by pressure-related vessel damage, leading to leaking of proteolytic enzymes and free radicals into the dermis. These processes lead to chronic inflammation resulting in stasis
dermatitis, lipodermatosclerosis, and eventually venous ulceration.

Venous ulcers are located most commonly around the medial malleolus (the gaiter area) and vary considerably in size and shape (Fig. 20-7). They are often large and shallow. They may be single or multiple. The ulcer margin is well defined but not raised or undermined. The ulcer base may show yellow and doughy or healthy red hemorrhagic granulation tissue.

Other features to look out for in the surrounding skin:

Venous ulcers are often painless. There may be a sensation of heaviness or aching or swelling of the lower leg particularly after prolonged standing. A history of preceding minor injury or infection may be elucidated.

Ankle brachial indices should be measured before compression therapy to assess for arterial disease. It should be noted that values are not reliable in diabetics. Compression is contraindicated if the value is less than 0.5 and a value less than 0.8 indicates arterial disease and caution should be used. A vascular surgery opinion should be sought in cases with decreased values. Venous duplex ultrasound allows visualization of the veins and flow through the valves. Patch tests should be performed if a component of contact dermatitis is suspected. The ulcer should be measured carefully (length, width, and depth). Consider photographing the ulceration at each visit to aid assessment of progress.