• An assessment should be carried out by a healthcare professional trained in leg ulcer management.
• Carry out Doppler studies to exclude arterial insufficiency.
• Ask about pain (site, nature, severity), odour, and discharge.
• Examine the legs for oedema and venous eczema.
• Look for signs of an infected leg ulcer such as:
• Enlarging ulcer.
• Increased exudate or pain.
• Pyrexia.
• Foul odour.
• Cellulitis — surrounding skin is red, hot, and non-scaling.
• Inspect and record details about the ulcer, to compare at follow up in order to determine how well the ulcer is healing. Assess:
• Size and depth — trace out the ulcer margin onto a transparent sheet, or if possible and appropriate, a photograph may be helpful. Examine to assess the depth of the ulcer.
• Wound bed — look for granulation, and fibrous or necrotic tissue which may need to be removed to allow healing. Look for exudate to help determine which dressing is needed.
• The ulcer edge often give a good indication of progress and should be carefully documented (for example shallow, epithelialising, punched out).
• The position of the ulcer(s) should be clearly described.
• Assess the impact that the symptoms are having on the person's quality of life. For example, can they move around and carry out normal activities of daily living such as shopping, housework, or employment?
• Assess risk factors (such as immobility or obesity) and comorbidities (such as diabetes mellitus or rheumatoid arthritis) which need treatment or referral to promote ulcer healing.

In depth

• A Doppler assessment of both legs and interpretation should be carried out on all people by an appropriately trained healthcare professional.
• An ankle brachial pressure index (ABPI) involves the measurement of a person's systolic blood pressure at their ankle and arm (brachial) using a Doppler machine. The ABPI provides an index of vessel competency by measuring the ratio of systolic blood pressure at the ankle to that in the arm, with a value of 1 being normal. When interpreting ABPI in a person with venous ulcer, a ratio of:
• Less than 0.5 indicates severe arterial insufficiency and compression treatment is contraindicated. Refer urgently to a specialist vascular clinic for further assessment.
• Between 0.5 and 0.8 indicates that the person has arterial disease. Refer to a specialist vascular clinic for further assessment. Compression bandaging should generally be avoided. However, reduced compression can be used under strict supervision (assess progress daily) if the ulcer is clinically venous and the healthcare professional has sufficient experience.
• Greater than 0.8 indicates that graduated compression bandages may be safely applied.
• Be aware that the ABPI may decrease after the initial measurement. Arterial disease may develop in people with venous disease, and the ABPI will also reduce with increasing age.
• People with diabetes mellitus, atherosclerotic disease, rheumatoid arthritis, and systemic vasculitis should be referred for a specialist assessment as the ABPI in these people may not be reliable. These conditions may give falsely high (and misleading) ABPI readings due to calcification of the blood vessels.

In depth

• Refer to secondary care a person with a non-healing venous leg ulcer (if there are no signs of improvement after 2–3 months of standard care) to exclude other causes of ulceration and complications.
• Review the person's compliance with compression therapy and lifestyle strategies and determine whether they have ongoing risk factors for venous leg ulceration.
• After assessment by a specialist and the exclusion of alternative causes of ulceration, aim to optimize the person's quality of life (as healing of the ulcer may not be an achievable outcome despite optimal management) by controlling symptoms, encouraging mobility, and providing long-term psychological support (if needed).

In depth

• In addition to compression bandaging (if appropriate), advise the person to elevate their legs (above hip level) for 30 minutes, three to four times a day, and consider placing pillows under their feet and legs while sleeping.
• Do not prescribe diuretic medication for persistent or worsening oedema: check compliance with advice given regarding reducing oedema, and exclude other causes of oedema such as medication and heart failure.

In depth

• Determine the duration, nature, and severity of the pain to exclude an additional cause. Worsening pain may indicate poor ulcer healing, arterial disease, diabetic neuropathy, or cellulitis.
• Advise the person that leg elevation will help with the pain associated with oedema.
• Prescribe paracetamol or a combination of paracetamol and codeine phosphate according to the severity of pain and the person's response to treatment. Do not routinely prescribe nonsteroidal anti-inflammatory drugs.

In depth

• Exclude cellulitis if there is worsening venous eczema and signs suggestive of active infection.
• Use an emollient and a mild to moderate potency topical corticosteroid ointment. If compression bandaging is being used, consider replacing bandages more frequently than once weekly to apply topical treatment. For more information see the CKS topic on Eczema - atopic.
• If there is no improvement with an emollient and a moderately potent topical corticosteroid, or there are concerns about allergic contact dermatitis (worsening rash with topical treatment at any stage), refer the person to Dermatology for consideration of patch testing, and advise them to avoid any allergens subsequently identified.

In depth