Venous leg ulcers (VLUs) are the most common type of leg ulcer,1 often resulting from chronic venous insufficiency.2 They can significantly impact patients’ quality of life and place a burden on healthcare systems. Effective diagnosis and treatment are key to improving outcomes. In this section, we explore how VLUs are diagnosed and managed, and how Essity’s product solutions can support each step of the therapeutic journey.
Diagnosis and prevention of complications
Timely diagnosis is essential to improve healing times and prevent complications.1 Initial and ongoing assessment should be holistic and include:3,4,5
Comprehensive patient medical history
- Comorbidities
- Medications
- Allergies Smoking, alcohol, and/or drug use
- Previous vascular procedures
- Lifestyle/psychosocial issues e.g. education, adherence to treatment plan, and capacity for self-care
Clinical assessment
- Clinical signs of infection and inflammation
- Arterial assessment
- Edema assessment
- Signs of chronic venous insufficiency
- Wound assessment including exudate and odor
- Pain
- Quality of life
Venous leg ulcer classification using CEAP
Figure title: CEAP grading of CVD (6)
Following diagnosis, CVD is classified with the international classification system: Clinical, Etiological, Anatomical, Pathological (CEAP).⁶ The first stage, or early stage, of venous leg ulcer, are spider veins, or reticular veins, which can appear blue, red, purple, brown, or darker depending on the skin tone.⁷ At Stage 2, varicose veins occur, distinguished from reticular veins by a diameter of 3 mm or more. At Stage 3, edema occurs. At Stage 4, there are changes in the skin and subcutaneous tissue secondary to CVD, which may present as pigmentation or eczema, or as lipodermatosclerosis or atrophie blanche. Stage 5 is a healed venous ulcer, whereas Stage 6 is an active venous ulcer.⁶
Current guidelines recommend that all patients with VLUs should receive a prompt holistic assessment, treatment of underlying disease, appropriate wound and skin management and compression therapy.⁸ At the physician’s discretion and in collaboration with the patient, VLUs may be managed in a primary care or community-based environment. Some patients may require referral to additional members of an multidisciplinary team, including physicians, nurses, enterostomal therapist specialists, dietitian, physiotherapists, compression stocking specialists and infectious disease specialists.⁹,¹⁰
The importance of regular reassessment
Following diagnosis, patients should be reassessed on a 4-weekly basis.⁹ Regular follow-up enables ongoing assessment to determine if symptoms are improving and if the current care plan is effective and remains appropriate.⁹ It is therefore important for the treating physician to build a sustainable relationship with the patient, diagnose and identify their needs and agree on a treatment plan that will suit the patient’s lifestyle.⁸
Red flag symptoms in venous leg ulcers
Immediate treatment and/or onward referral is required when red flags symptoms are identified.11
Red flag symptoms include:11
- Acute infection
- Symptoms of sepsis
- Acute or suspected chronic limb threatening ischemia
- Suspected acute deep vein thrombosis
- Suspected skin cancer
- Bleeding varicose veins
Treatment strategies for chronic venous ulcers
Non-viable tissue
Observations
- Slough or necrotic tissue
Treatment objectives
- Remove the non-viable tissue by debridement to aid wound progression
- Diabetic foot wounds must be referred to podiatrist prior to any debridement
Dressing/treatment options
- Selective sharp or surgical (e.g. scalpel, scissors, curette)
- Mechanical (e.g. debridement pad)
- Biological (larval therapy)
- Enzymatic
- Moisture-donating dressings
Suggested products
- Cutimed® Gel – hydrogel which hydrates and supports autolytic debridement, with a cooling effect
- Cutimed® Sorbact Hydro® – supports infection management and autolytic debridement in one dressing
Desired clinical outcome
- Viable wound base
Inflammation of infection
Observations
- Pain, redness, swelling, heat, odor, pus, exudate, friable granulation tissue
Treatment objectives
- Reduce bacterial load to manage infection or inflammation
Dressing/treatment options
- Local/systemic infection: consider topical antimicrobial or bacteria-binding dressings
- For high-risk patients that require prophylactic treatment consider using an antimicrobial product
Suggested products
- Cutimed® Sorbact® - Dressings with Sorbact® Technology irreversible bind bacteria to the DACC™-coated surface for an antibacterial effect without the release of active substances. This delivers safe and effective wound infection management and supports wound healing
Desired clinical outcome
- Bacterial balance, reduced inflammation and wound progression
Moisture imbalance
Observations
- Heavy exudate, risk of maceration/excoriation
- Dry wound
- Friable skin
- Consider underlying cause of exudate and identify if compression therapy might be necessary
Treatment objectives
- Aim for a balanced and optimal moist wound healing environment
- Choose a dressing to either absorb the excess exudate, or add moisture to dry wounds
Dressing/treatment options
- High exudate – NPWT, superabsorbers, hydrofibers, alginates or foams
- Low exudate – hydrocolloids, hydrogels, films, moisture balancing dressing
- If maceration/excoriation present, consider barrier preparation to protect vulnerable skin.
- NB: If patient has leg ulceration, compression should be part of the treatment, where the ABPI permits.
Suggested products
- Cutimed® Siltec® - gentle foam dressings for reliable exudate management, also under compression
- Cutimed® Sorbion® - range of superabsorbent dressings for effective exudate management for low to excessive exuding wounds even under compression12
- Cutimed® Gelling Fiber - absorbs wound fluid and transforms into a soft gel, which maintains a moist environment, can be used under compression
Desired clinical outcome
- Optimal moist wound healing environment
Advancing/non-advancing edges
Observations
- Advancing, epithelialization visible or non-advancing e.g. undermining, rolled edges
Treatment objectives
- If wound shows signs of epithelialization, continue with treatment. If not, re-assess wound
Dressing/treatment options
- Barrier preparations (e.g. barrier creams, ointments or films) wound contact layers to help prevent pain and trauma
Suggested products
- Cutimed® PROTECT - spray, foam applicator or cream which provide a long-lasting protective barrier against bodily fluids, especially those associated with incontinence
- Cuticell® Contact - a silicone wound contact layer for atraumatic dressing changes and undisturbed wound healing13
Desired clinical outcome
- Advancing edge of wound, healthy peri-wound skin and signs of progression to wound closure
Compression therapy for venous leg ulcers
Compression should be used as early as possible as part of a holistic management program3,4,8. Compression to support venous function and address underlying venous insufficiency4 remains the first-line treatment in both acute and chronic VLU management as indicated in venous leg ulcer NICE Guidelines14, EMWA 2023 Guidelines3, the JWC International Consensus Document 20247 and the 2016 S3-Guideline of the European Dermatology Forum.15
Compression has anti-inflammatory properties and reduces pain, exudate and associated skin problems.4 This contributes to decreasing healing times and risk of recurrence.4 In addition to compression, it is essential to keep the VLU clean to avoid infection.4 Once the VLU has healed, a treatment care plan should be put in place to prevent recurrence.8
Cutimed® and JOBST® offer a full spectrum of solutions for an integrated holistic approach
Cutimed‘s treatments are an effective, easy-to-use, clinically proven option to manage chronic wounds, including VLUs, supported by robust clinical evidence.
Products for venous leg ulcers include advanced wound care products such as Cutimed Sorbact, Cutimed Sorbion and Cutimed Siltec. These can be combined with compression therapy from JOBST, including JOBST UlcerCare®, JOBST UlcerCare Liners, JOBST FarrowWrap®, JOBST Compri2®, and JOBST Compri2 Lite.
Compression hosiery like JOBST UlcerCare, JOBST FarrowWrap, and JOBST Compri2 ensures the fastest healing time and helps reduce the risk of further complications.9 Further information on compression products can be found at jobstcanada.com.
Disclaimer
This article is intended to be used as an information guide to be considered when the organization makes clinical decisions and does not constitute medical advice. For detailed device information, including indications for use, contraindications, effects, precautions, and warnings, please consult the product’s Instructions for Use (IFU) before use. In case of doubt please consult a healthcare professional.
References
- Chamanga ET. Understanding venous leg ulcers. Br J Community Nurs. 2018;23(Sup9):6-15.
- Fukaya E et al. Vascular disease patient information page: venous leg ulcers. Vasc Med. 2023;28(1):89-92.
- European Wound Management Association. Lower leg ulcer diagnosis and principles of treatment. Journal of Wound Management. 2023; accessed February 1, 2025. https://doi.org/10.35279/jowm2023.24.02.sup01.
- Mosti G. Leg ulceration in venous and arteriovenous insufficiency: assessment and management with compression therapy. Wound Care. 2024;33(10 Sup B).
- Isoherranen K et al. Lower leg ulcer diagnosis & principles of treatment, including recommendations for comprehensive assessment and referral pathways. J Wound Management, 2023;24(2 Sup1):s1-76.
- Eklöf B et al. Revision of the CEAP classification for chronic venous disorders: Consensus statement. J Vasc Surg. 2004;40(6):1248-1252.
- Dhoonmoon L et al. International Consensus Document: Wound care and skin tone signs, symptoms and terminology for all skin tones. Wounds International. 2023.
- Fletcher J et al. Best practice statement: holistic management of venous leg ulceration (second edition). Wounds UK. 2022.
- Fletcher J et al. Best practice statement: holistic management of venous leg ulceration (second edition). Wounds UK. 2016.
- Kozell K et al. Assessment and management of venous leg ulcers. Registered Nurses’ Association of Ontario. 2006. accessed February 1, 2025. https://rnao.ca/media/5913/download.
- National Wound Care Strategy Programme. Leg and foot ulcers. Accessed December 10, 2024. https://www.nationalwoundcarestrategy.net/lower-limb/
- Essity Group. Commissioned laboratory testing at SMTL. Evaluation of absorbency and fluid retention of different superabsorbent wound dressings (based on EN 13726). Published online 2024.
- Derbyshire A. Using a silicone-based dressing as a primary wound contact layer. Br J Nurs. 2014;23(Sup20):S14-S20.
- NICE. Scenario: Venous leg ulcers | Management | Leg ulcer - venous | CKS | NICE. Accessed December 11, 2024. https://cks.nice.org.uk/topics/leg-ulcer-venous/management/venous-leg-ulcers
- Neumann HAM. Evidence‐based (S3) guidelines for diagnostics and treatment of venous leg ulcers. J Eur Acad Dermatol Venereol. 2016;30(11):1843-1875.