Venous Leg Ulcers: Assessment, Treatment, and Prevention

Venous leg ulcers are the most common leg wound, they are largely a pressure problem rather than a wound problem, and they heal with compression. That last sentence is the whole page in miniature — but the compression only goes on after someone has checked the arteries.

What a venous ulcer looks like

It sits in the gaiter area — the band between the ankle and the calf — and most often just above the inner ankle bone. It is shallow with an irregular border, the base is usually pink or yellow and moist rather than dry, and it weeps. It is often uncomfortable rather than severe, and the discomfort typically eases when the leg is raised.

The skin around it has usually been telling the story for years: brown or rusty staining, dry itchy flaking, swelling that comes and goes with the day, and sometimes a hardened, tight, narrowed band above the ankle that makes the leg look like an inverted champagne bottle. Those skin changes come first, and recognizing them is the chance to prevent the ulcer entirely.

Telling the three common ulcers apart

Mixed ulcers exist, and they are common enough that the assessment below is not optional in anyone.

What the assessment should include

1. An ankle-brachial index before any compression. This is the single most important step, and it is the one most often skipped. Compression on a leg with significant arterial disease can cause harm.
2. A look at the whole leg and both feet, not just the wound — including between the toes.
3. Measurement of the ulcer, so progress is a fact rather than an impression. Photographs with a ruler in frame work well.
4. Duplex ultrasound of the leg veins to find which veins are leaking. This is what makes treatment of the underlying cause possible.
5. Blood tests for diabetes, anemia, kidney function and nutrition, which all affect healing.
6. A swab only if infection is suspected. Every open wound grows bacteria; a positive swab from a wound that looks fine is not a reason for antibiotics.
7. A biopsy if it has not healed in about three months despite proper treatment. A small number of long-standing ulcers turn out to be something else, including skin cancer, and this is how that gets found.

What actually heals them

Compression is the treatment. Not the dressing, not an antibiotic, not a cream — compression. Applied properly, at a strong enough level, and worn continuously, it heals the majority of venous ulcers. Multi-layer bandaging applied by someone trained in it is the usual approach while the ulcer is open, moving to fitted stockings once it closes. If compression is uncomfortable to the point that you take it off, say so rather than abandoning it, because there are several systems and a different one often works. Safety first, then fit.

Treating the underlying vein problem changes the outcome. Closing the leaking veins — usually with a catheter-based technique done under local anesthetic — helps ulcers heal faster and, more importantly, makes them much less likely to come back. Current practice is to do this early rather than waiting for the ulcer to close first. How the underlying problem works.

The rest supports those two. Simple non-adherent dressings chosen for how much fluid the wound produces, rather than expensive ones. Raising the legs above heart level for periods during the day. Walking and ankle exercises, which work the calf muscle pump. Treating the surrounding eczema. Attention to protein intake and blood sugar. A prescription medicine is sometimes added to speed healing in stubborn ulcers.

Keeping it closed

This is the part that gets least attention and matters most. Without ongoing compression, a large share of healed venous ulcers return within a year. With fitted stockings worn daily, that drops substantially. The plan after healing should include: correctly measured and fitted stockings at the right strength, a replacement schedule — they lose their compression over a few months of wear — treatment of any leaking veins that have not been addressed, daily skin care and moisturizing, and a low threshold for getting any new break in the skin looked at early. Getting the fit right.

Common questions

How long does a venous ulcer take to heal?

With proper compression, many close within three to four months, and smaller ones considerably faster. A useful rule is that an ulcer getting meaningfully smaller over four weeks is on track; one that is not is a reason to re-examine the diagnosis, the compression, or both — rather than to keep doing the same thing for another month.

Why do I need compression if the wound is on my skin?

Because the wound is a symptom of pressure. Failing valves let blood fall back down the leg, pressure in the small vessels stays high, fluid and inflammatory cells leak into the tissue, and the skin eventually breaks down. Compression counteracts that pressure. Treating the surface without treating the pressure is why some ulcers stay open for years.

Can I get it wet or shower?

Showering is usually fine with the wound covered, and your team will tell you what suits the dressing you have. What to avoid is soaking the leg in a bath or a basin for long periods, and harsh soaps and antiseptics on the wound itself.

My ulcer smells. Is it infected?

Not necessarily. Heavily exuding wounds and some dressings smell without infection being present. The signs that matter are spreading redness and warmth, increasing pain, fever, and the wound getting bigger. Any of those together with odor should be seen the same day.

Should I have my veins treated if the ulcer is already healing?

It is worth asking about. Closing the refluxing veins is what reduces the chance of the ulcer returning, and recurrence is the main long-term problem with venous ulcers. Ask for a duplex ultrasound and a conversation about it rather than assuming that a healed ulcer means the job is finished.

Written by Tom Biernacki, DPM, FACFAS. Published 21 September 2026. General education, not medical advice.