What a venous ulcer is
A venous leg ulcer is an open wound, usually on the inner side of the leg just above the ankle, in skin that has been under high venous pressure for years. It is the end of the road that starts with aching legs and evening swelling, passes through brown staining and thickened skin, and finishes when tissue that has been inflamed and starved for long enough finally breaks down.
They are the most common type of leg ulcer by a wide margin, and they are notorious for healing and then returning — because the thing that caused them is usually still there.
The part that is frequently missed
A venous ulcer looks like a wound, so it tends to be treated as one: dressings, creams, wound clinics, weeks of careful management. All of that has a role. None of it addresses why the skin broke down.
Underneath most of these ulcers is venous reflux — a vein whose valves have failed, letting blood fall back down the leg and pressure build in the tissue around the ankle. Until that pressure comes down, the skin is being asked to heal in conditions that caused it to fail. When the reflux is treated, ulcers that have resisted months of dressings often begin to close, and the chance of recurrence drops substantially.
What happens at the first appointment
Three things.
The leg is examined and the ulcer assessed — where it sits, how long it has been there, what the surrounding skin is doing. Arterial circulation is checked, because compression is central to venous ulcer treatment and is the wrong thing entirely for an ulcer caused by poor arterial supply. And a duplex ultrasound maps the venous system to establish whether reflux is present and which vein is responsible.
By the end of that appointment you should know what kind of ulcer you have and what is driving it.
Treatment
Compression is the foundation, once arterial supply has been confirmed as adequate. Correctly applied graduated compression is the single most effective thing for healing a venous ulcer, and it is also the thing most often done at too low a pressure to work.
The refluxing vein is closed — radiofrequency ablation or Varithena® microfoam, in the office, under local anaesthetic. This is the step that changes the underlying conditions rather than managing them.
Wound care continues alongside, and coordination with whoever has been dressing the wound is part of the job rather than a handover.
Afterwards
Healing is measured in weeks to months, not days, and the pace depends on how long the ulcer has been open. The more important number is recurrence: skin that healed under compression alone, over an untreated refluxing vein, breaks down again with depressing regularity. Skin that healed after the reflux was corrected is far more likely to stay closed. Compression usually continues after healing for exactly that reason.