Management of Venous Leg Ulcers

Publication Date: August 1, 2014
Last Updated: September 2, 2022

Diagnosis

Definition

We suggest use of a standard definition of venous ulcer as an open skin lesion of the leg or foot that occurs in an area affected by venous hypertension. (BP)
685

Venous Anatomy and Pathophysiology

Venous Anatomy Nomenclature

We recommend use of the International Consensus Committee on Venous Anatomical Terminology for standardized venous anatomy nomenclature. (BP)
[Tables 1 and 2]
685

Venous Leg Ulcer Pathophysiology

We recommend a basic practical knowledge of venous physiology and venous leg ulcer pathophysiology for all practitioners caring for venous leg ulcers. (BP)
685

Clinical Evaluation

We recommend that for all patients with suspected leg ulcers fitting the definition of venous leg ulcer, clinical evaluation for evidence of chronic venous disease be performed. (BP)
685

Nonvenous Causes of Leg Ulcers

We recommend identification of medical conditions that affect ulcer healing and other nonvenous causes of ulcers. (BP)
685

Wound Documentation

We recommend serial venous leg ulcer wound measurement and documentation. (BP)
685

Wound Culture

We suggest against routine culture of venous leg ulcers and only to obtain wound culture specimens when clinical evidence of infection is present. (2-C)
685

Wound Biopsy

We recommend wound biopsy for leg ulcers that do not improve with standard wound and compression therapy after 4–6 weeks of treatment and for all ulcers with atypical features. (1-C)
685

Laboratory Evaluation

We suggest laboratory evaluation for thrombophilia for patients with a history of recurrent venous thrombosis and chronic recurrent venous leg ulcers (2-C)
685

Arterial Testing

We recommend arterial pulse examination and measurement of ankle-brachial index on all patients with venous leg ulcer. (1-B)
685

Microcirculation Assessment

We suggest against routine microcirculation assessment of venous leg ulcers but suggest selective consideration as an adjunctive assessment for monitoring of advanced wound therapy. (2-C)
685

Venous Duplex Ultrasound

We recommend comprehensive venous duplex ultrasound examination of the lower extremity in all patients with suspected venous leg ulcer. (1-B)
685

Venous Plethysmography

We suggest selective use of venous plethysmography in the evaluation of patients with suspected venous leg ulcer if venous duplex ultrasound does not provide definitive diagnostic information. (2-B)
685

Venous Imaging

We suggest selective computed tomography venography, magnetic resonance venography, contrast venography, and/or intravascular ultrasound in patients with suspected venous leg ulceration if additional advanced venous diagnosis is required for thrombotic or nonthrombotic iliac vein obstruction or for operative planning before open or endovenous interventions. (2-C)
685

Venous Disease Classification

We recommend that all patients with venous leg ulcer be classified on the basis of venous disease classification assessment, including clinical CEAP, revised Venous Clinical Severity Score, and venous disease-specific quality of life assessment. (BP)
685

Venous Procedural Outcome Assessment

We recommend venous procedural outcome assessment including reporting of anatomic success, venous hemodynamic success, procedure-related minor and major complications, and impact on venous leg ulcer healing. (BP)
685

Treatment

Wound Care

Wound Cleansers

We suggest that venous leg ulcers be cleansed initially and at each dressing change with a neutral, nonirritating, nontoxic solution, performed with a minimum of chemical or mechanical trauma. (2-C)
685

Débridement

We recommend that venous leg ulcers receive thorough débridement at their initial evaluation to remove obvious necrotic tissue, excessive bacterial burden, and cellular burden of dead and senescent cells. (1-B)
685
We suggest that additional maintenance débridement be performed to maintain the appearance and readiness of the wound bed for healing. (2-B)
685
We suggest that the health care provider choose from a number of débridement methods, including sharp, enzymatic, mechanical, biologic, and autolytic. More than one débridement method may be appropriate. (2-B)
685

Anesthesia for Surgical Débridement

We recommend that local anesthesia (topical or local injection) be administered to minimize discomfort associated with surgical venous leg ulcer débridement. In selected cases, regional block or general anesthesia may be required. (1-B)
685

Surgical Débridement

We recommend that surgical débridement be performed for venous leg ulcers with slough, nonviable tissue, or eschar. Serial wound assessment is important in determining the need for repeated débridement. (1-B)
685

Hydrosurgical Débridement

We suggest hydrosurgical débridement as an alternative to standard surgical débridement of venous leg ulcers. (2-B)
685

Ultrasonic Débridement

We suggest against ultrasonic débridement over surgical débridement in the treatment of venous leg ulcers. (2-C)
685

Enzymatic Débridement

We suggest enzymatic débridement of venous leg ulcers when no clinician trained in surgical débridement is available to débride the wound. (2-C)
685
We do NOT suggest enzymatic débridement over surgical débridement. (2-C)
685

Biologic Débridement

We suggest that larval therapy for venous leg ulcers can be used as an alternative to surgical débridement. (2-B)
685

Management of Limb Cellulitis

We recommend that cellulitis (inflammation and infection of the skin and subcutaneous tissue) surrounding the venous leg ulcer be treated with systemic gram-positive antibiotics. (1-B)
685

Wound Colonization and Bacterial Biofilms

We suggest against systemic antimicrobial treatment of venous leg ulcer colonization or biofilm without clinical evidence of infection (2-C)
685

Treatment of Wound Infection

We suggest that venous leg ulcers with >106 colony-forming units per gram of tissue (CFU/g) and clinical evidence of infection be treated with antimicrobial therapy. (2-C)
685
We suggest antimicrobial therapy for virulent or difficult to eradicate bacteria (such as beta-hemolytic streptococci, pseudomonas, and resistant staphylococcal species) at lower levels of CFU/g. (2-C)
685
We suggest a combination of mechanical disruption and antibiotic therapy as most likely to be successful in eradicating venous leg ulcer infection. (2-C)
685

Systemic Antibiotics

We recommend that venous leg ulcers with clinical evidence of infection be treated with systemic antibiotics guided by sensitivities performed on wound culture. (1-C)
685
Oral antibiotics are preferred initially, and the duration of antibiotic therapy should be limited to 2 weeks unless persistent evidence of wound infection is present. (1-C)
685

Topical Antibiotics for Infected Wounds

We suggest against use of topical antimicrobial agents for the treatment of infected venous leg ulcers. (2-C)
685

Topical Dressing Selection

We suggest applying a topical dressing that will manage venous leg ulcer exudate and maintain a moist, warm wound bed. (2-C)
685
We suggest selection of a primary wound dressing that will absorb wound exudate produced by the ulcer (alginates, foams) and protect the periulcer skin. (2-B)
685

Topical Dressings Containing Antimicrobials

We recommend against the routine use of topical antimicrobial-containing dressings in the treatment of noninfected venous leg ulcers. (2-A)
685

Periulcer Skin Management

We suggest application of skin lubricants underneath compression to reduce dermatitis that commonly affects periulcer skin. (2-C)
685
In severe cases of dermatitis associated with venous leg ulcers, we suggest topical steroids to reduce the development of secondary ulcerations and to reduce the symptoms of dermatitis. (2-C)
685

Anti-inflammatory Therapies

We suggest against use of anti-inflammatory therapies for the treatment of venous leg ulcers. (2-C)
685

Indications for Adjuvant Therapies

We recommend adjuvant wound therapy options for venous leg ulcers that fail to demonstrate improvement after a minimum of 4–6 weeks of standard wound therapy. (1-B)
685

Split-thickness Skin Grafting

We suggest against split-thickness skin grafting as primary therapy in treatment of venous leg ulcers. (2-B)
685
We suggest split-thickness skin grafting with continued compression for selected large venous leg ulcers that have failed to show signs of healing with standard care for 4–6 weeks. (2-B)
685

Cellular Therapy

We suggest the use of cultured allogeneic bilayer skin replacements (with both epidermal and dermal layers) to increase the chances for healing in patients with difficult to heal venous leg ulcers in addition to compression therapy in patients who have failed to show signs of healing after standard therapy for 4–6 weeks. (2-A)
685

Preparation for Cellular Therapy

We suggest a therapeutic trial of appropriate compression and wound bed moisture control before application of cellular therapy. (2-C)
685
We recommend that adequate wound bed preparation, including complete removal of slough, debris, and any necrotic tissue, be completed before the application of a bilayered cellular graft. (1-C)
685
We recommend additional evaluation and management of increased bioburden levels before the application of cellular therapy. (1-C)
685

Frequency of Cellular Therapy Application

We suggest reapplication of cellular therapy as long as the venous leg ulcer continues to respond on the basis of wound documentation. (2-C)
685

Tissue Matrices, Human Tissues, or Other Skin Substitutes

We suggest the use of a porcine small intestinal submucosal tissue construct in addition to compression therapy for the treatment of venous leg ulcers that have failed to show signs of healing after standard therapy for 4–6 weeks. (2-B)
685

Negative Pressure Therapy

We suggest against routine primary use of negative pressure wound therapy for venous leg ulcers. (2-C)
685

Electrical Stimulation

We suggest against electrical stimulation therapy for venous leg ulcers. (2-C)
685

Ultrasound Therapy

We suggest against routine ultrasound therapy for venous leg ulcers. (2-B)
685

Compression

Compression–Ulcer Healing

In a patient with a venous leg ulcer, we recommend compression therapy over no compression therapy to increase venous leg ulcer healing rate. (1-A)
685

Compression–Ulcer Recurrence

In a patient with a healed venous leg ulcer, we suggest compression therapy to decrease the risk of ulcer recurrence. (2-B)
685

Multicomponent Compression Bandage

We suggest the use of multicomponent compression bandage over single-component bandages for the treatment of venous leg ulcers. (2-B)
685

Compression–Arterial Insufficiency

In a patient with a venous leg ulcer and underlying arterial disease, we do NOT suggest compression bandages or stockings if the ankle-brachial index is 0.5 or less or if absolute ankle pressure is <60 mm Hg. (2-C)
685

Intermittent Pneumatic Compression

We suggest use of intermittent pneumatic compression when other compression options are not available, cannot be used, or have failed to aid in venous leg ulcer healing after prolonged compression therapy. (2-C)
685

Operative/Endovascular Management

Superficial Venous Reflux and Active Venous Leg Ulcer–Ulcer Healing

In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we suggest ablation of the incompetent veins in addition to standard compressive therapy to improve ulcer healing. (2-C)
685

Superficial Venous Reflux and Active Venous Leg Ulcer–Prevent Recurrence

In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we recommend ablation of the incompetent veins in addition to standard compressive therapy to prevent recurrence. (1-B)
685

Superficial Venous Reflux and Healed Venous Leg Ulcer

In a patient with a healed venous leg ulcer (C5) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we recommend ablation of the incompetent veins in addition to standard compressive therapy to prevent recurrence. (1-C)
685

Superficial Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b)

In a patient with skin changes at risk for venous leg ulcer (C4b) and incompetent superficial veins that have axial reflux directed to the bed of the affected skin, we suggest ablation of the incompetent superficial veins in addition to standard compressive therapy to prevent ulceration. (2-C)
685

Combined Superficial and Perforator Venous Reflux With or Without Deep Venous Reflux and Active Venous Leg Ulcer

In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have reflux to the ulcer bed in addition to pathologic perforating veins (outward flow of 500 ms duration, with a diameter of 3.5 mm) located beneath or associated with the ulcer bed, we suggest ablation of both the incompetent superficial veins and perforator veins in addition to standard compressive therapy to aid in ulcer healing and to prevent recurrence. (2-C)
685

Combined Superficial and Perforator Venous Reflux With or Without Deep Venous Disease and Skin Changes at Risk for Venous Leg Ulcer (C4b) or Healed Venous Ulcer (C5)

In a patient with skin changes at risk for venous leg ulcer (C4b) or healed venous ulcer (C5) and incompetent superficial veins that have reflux to the ulcer bed in addition to pathologic perforating veins (outward flow of 500 ms duration, with a diameter of 3.5 mm) located beneath or associated with the healed ulcer bed, we suggest ablation of the incompetent superficial veins to prevent the development or recurrence of a venous leg ulcer. (2-C)
685
Treatment of the incompetent perforating veins can be performed simultaneously with correction of axial reflux or can be staged with re-evaluation of perforator veins for persistent incompetence after correction of axial reflux. (2-C)
685

Pathologic Perforator Venous Reflux in the Absence of Superficial Venous Disease, With or Without Deep Venous Reflux, and a Healed or Active Venous Ulcer

In a patient with isolated pathologic perforator veins (outward flow of 500 ms duration, with a diameter of 3.5 mm) located beneath or associated with the healed (C5) or active ulcer (C6) bed regardless of the status of the deep veins, we suggest ablation of the “pathologic” perforating veins in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. (2-C)
685

Treatment Alternatives for Pathologic Perforator Veins

For those patients who would benefit from pathologic perforator vein ablation, we recommend treatment by percutaneous techniques that include ultrasound-guided sclerotherapy or endovenous thermal ablation (radiofrequency or laser) over open venous perforator surgery to eliminate the need for incisions in areas of compromised skin. (1-C)
685

Infrainguinal Deep Venous Obstruction and Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer

In a patient with infrainguinal deep venous obstruction and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest autogenous venous bypass or endophlebectomy in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. (2-C)
685

Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer–Ligation

In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest against deep vein ligation of the femoral or popliteal veins as a routine treatment. (2-C)
685

Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer–Primary Valve Repair

In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest individual valve repair for those who have axial reflux with structurally preserved deep venous valves in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. (2-C)
685

Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer–Valve Transposition or Transplantation

In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest valve transposition or transplantation for those with absence of structurally preserved axial deep venous valves when competent outflow venous pathways are anatomically appropriate for surgical anastomosis in addition to standard compression therapy to aid in venous leg ulcer healing and to prevent recurrence. (2-C)
685

Deep Venous Reflux With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer–Autogenous Valve Substitute

In a patient with infrainguinal deep venous reflux and skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we suggest consideration of autogenous valve substitutes by surgeons experienced in these techniques to facilitate ulcer healing and to prevent recurrence in those with no other option available in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. (2-C)
685

Proximal Chronic Total Venous Occlusion/Severe Stenosis With Skin Changes at Risk for Venous Leg Ulcer (C4b), Healed (C5) or Active (C6) Venous Leg Ulcer–Endovascular Repair

In a patient with inferior vena cava or iliac vein chronic total occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, that is associated with skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we recommend venous angioplasty and stent recanalization in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. (1-C)
685

Proximal Chronic Venous Occlusion/Severe Stenosis (Bilateral) With Recalcitrant Venous Ulcer–Open Repair

In a patient with inferior vena cava or iliac vein chronic occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, that is associated with a recalcitrant venous leg ulcer and failed endovascular treatment, we suggest open surgical bypass with use of an externally supported expanded polytetrafluoroethylene graft in addition to standard compression therapy to aid in venous leg ulcer healing and to prevent recurrence. (2-C)
685
Unilateral Iliofemoral Venous Occlusion/Severe Stenosis With Recalcitrant Venous Ulcer–Open Repair
In a patient with unilateral iliofemoral venous occlusion/severe stenosis with recalcitrant venous leg ulcer for whom attempts at endovascular reconstruction have failed, we suggest open surgical bypass with use of saphenous vein as a cross-pubic bypass (Palma procedure) to aid in venous ulcer healing and to prevent recurrence. A synthetic graft is an alternative in the absence of autogenous tissue. (2-C)
685

Proximal Chronic Total Venous Occlusion/Severe Stenosis (Bilateral or Unilateral) With Recalcitrant Venous Ulcer–Adjunctive Arteriovenous Fistula

For those patients who would benefit from an open venous bypass, we suggest the addition of an adjunctive arteriovenous fistula (4–6 mm in size) as an adjunct to improve inflow into autologous or prosthetic crossover bypasses when the inflow is judged to be poor to aid in venous leg ulcer healing and to prevent recurrence. (2-C)
685

Ancillary Measures

Nutrition Assessment and Management

We recommend that nutrition assessment be performed in any patient with a venous leg ulcer who has evidence of malnutrition and that nutritional supplementation be provided if malnutrition is identified. (BP)
685

Systemic Drug Therapy

For long-standing or large venous leg ulcer, we recommend treatment with either pentoxifylline or micronized purified flavonoid fraction used in combination with compression therapy. (1-B)
685

Physiotherapy

We suggest supervised active exercise to improve muscle pump function and to reduce pain and edema in patients with venous leg ulcers. (2-B)
685

Manual Lymphatic Drainage

We suggest against adjunctive lymphatic drainage for healing of the chronic venous leg ulcers. (2-C)
685

Balneotherapy

We suggest balneotherapy to improve skin trophic changes and quality of life in patients with advanced venous disease. (2-B)
685

Ultraviolet light

We suggest against use of ultraviolet light for the treatment of venous leg ulcers. (2-C)
685

Primary Prevention

Primary Prevention–Clinical CEAP C3-4 Primary Venous Disease

In patients with clinical CEAP C3-4 disease due to primary valvular reflux, we recommend compression, 20–30 mm Hg, knee or thigh high. (2-C)
685

Primary Prevention–Clinical CEAP C1-4 Post-thrombotic Venous Disease

In patients with clinical CEAP C1-4 disease related to prior deep venous thrombosis (DVT), we recommend compression, 30–40 mm Hg, knee or thigh high. (1-B)
685

Guideline 8.3. Primary Prevention–Acute DVT Treatment

As post-thrombotic syndrome is a common preceding event for venous leg ulcers, we recommend current evidence-based therapies for acute DVT treatment. (1-B)
685
We suggest use of low-molecular-weight heparin over vitamin K antagonist therapy of 3-month duration to decrease postthrombotic syndrome. (2-B)
685
We suggest catheter-directed thrombolysis in patients with low bleeding risk with iliofemoral DVT of duration <14 days. (2-B)
685

Primary Prevention–Education Measures

In patients with C1-4 disease, we suggest patient and family education, regular exercise, leg elevation when at rest, careful skin care, weight control, and appropriately fitting foot wear. (BP)
685

Primary Prevention–Operative Therapy

In patients with asymptomatic C1-2 disease from either primary or secondary causes, we suggest against prophylactic interventional therapies to prevent venous leg ulcer. (2-C)
685

Recommendation Grading

Overview

Title

Management of Venous Leg Ulcers

Authoring Organizations

Publication Month/Year

August 1, 2014

Last Updated Month/Year

May 30, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Target Provider Population

Specialists who treat vascular diseases and wounds

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D007871 - Leg Ulcer, D014647 - Varicose Ulcer

Keywords

Venous leg ulcers, Venous ulcer, VLU