Pictures of Leg Ulcers With Diabetes: Common Signs and Care

Diabetes can lead to complications affecting circulation and nerve function, increasing the risk of leg ulcers. These wounds heal slowly and can worsen without proper care, making early recognition crucial to preventing severe outcomes such as infection or amputation.

Understanding their presentation and progression is key to effective management.

Common Signs In Early Wound Presentation

The earliest signs of a diabetic leg ulcer can be subtle, making detection challenging. Persistent redness or darkened skin, often warmer than the surrounding area, may indicate underlying inflammation or pressure-related damage before an open wound forms. Individuals with diabetic neuropathy may not feel pain, delaying recognition.

As the skin breaks down, a shallow wound may develop, often accompanied by a thin, yellowish or clear fluid discharge. While this is a natural response to injury, excessive moisture can encourage bacterial growth. The ulcer’s edges may appear irregular or slightly raised, and the surrounding skin may become dry, flaky, or calloused, particularly in areas subject to repeated friction or pressure, such as the shins, ankles, or heels.

A callus around the wound site is another warning sign. In diabetic individuals, callus formation increases pressure on underlying tissues, leading to further breakdown. Studies show that professional callus removal can reduce ulcer progression. Additionally, diminished hair growth and a shiny skin appearance may indicate compromised circulation, impairing healing.

Classification By Appearance

Diabetic leg ulcers fall into three primary categories based on their underlying cause and visual characteristics: neuropathic, ischemic, and neuroischemic ulcers. Recognizing these distinctions helps guide treatment.

Neuropathic Ulcers

Neuropathic ulcers result from prolonged pressure or repetitive trauma in individuals with diabetic peripheral neuropathy. Since nerve damage reduces sensation, minor injuries can go unnoticed, worsening over time. These ulcers typically appear on weight-bearing areas such as the soles of the feet, heels, or toes.

A defining feature is their well-defined, punched-out appearance with a surrounding rim of callused skin. The wound bed is usually moist with granulation tissue, indicating healing, but may contain yellowish slough if bacterial colonization occurs. Unlike ischemic ulcers, neuropathic wounds generally have good blood supply, so the surrounding skin remains pink or normal in color. Studies emphasize the importance of offloading pressure with specialized footwear or orthotic devices to prevent further tissue breakdown.

Ischemic Ulcers

Ischemic ulcers result from inadequate blood flow due to peripheral arterial disease (PAD), a common diabetes complication. These ulcers often develop on the toes, lateral foot margins, or areas prone to minor trauma. Poor circulation prevents oxygen and nutrients from reaching the tissue, leading to slow or non-healing wounds.

These ulcers typically have irregular borders and a dry, necrotic wound bed with black or brown eschar. The surrounding skin may be pale, cool to the touch, or bluish due to reduced perfusion. Unlike neuropathic ulcers, ischemic wounds are often painful, particularly when the leg is elevated, as gravity further limits blood flow. Research highlights that revascularization procedures, such as angioplasty or bypass surgery, can improve healing in cases of severe arterial insufficiency.

Neuroischemic Ulcers

Neuroischemic ulcers result from a combination of nerve damage and poor circulation, making them particularly difficult to manage. These wounds commonly occur on the edges of the foot, heels, or toes, where both pressure and vascular insufficiency contribute to tissue breakdown.

Unlike purely neuropathic ulcers, neuroischemic wounds tend to have irregular, shallow borders with a mix of necrotic and granulating tissue. The surrounding skin often appears thin, shiny, and hairless, reflecting compromised blood supply. Due to neuropathy and ischemia, these ulcers may not be painful despite significant tissue damage. Studies suggest that neuroischemic ulcers have a higher risk of infection and delayed healing, necessitating a multidisciplinary approach that includes vascular assessment, pressure offloading, and meticulous wound care.

Typical Locations On The Legs

Diabetic leg ulcers develop in areas where prolonged pressure, friction, or reduced blood flow compromise skin integrity. The lower extremities are particularly vulnerable due to neuropathy and vascular insufficiency, which impair the body’s ability to detect and heal minor injuries.

The feet bear much of the body’s weight, making them a primary site for ulcer formation. The plantar surface, especially the ball of the foot and heel, is at high risk due to constant pressure during walking and standing. Research indicates that up to 85% of diabetic foot ulcers originate in these areas, where mechanical stress leads to callus buildup and tissue breakdown. The toes, particularly the tips and interdigital spaces, are also common locations, as they are prone to friction from footwear and minor trauma that may go unnoticed due to sensory loss.

Beyond the feet, ulcers frequently develop around the ankles and shins, where the skin is thinner and more susceptible to external forces. The anterior shin is especially vulnerable to minor abrasions, which can escalate into chronic wounds due to impaired healing. Studies suggest that individuals with diabetes experience a prolonged inflammatory phase in wound healing, making superficial injuries more likely to become non-healing ulcers. Additionally, the medial malleolus—located on the inner side of the ankle—is a frequent site for ulceration, often linked to venous insufficiency that worsens fluid retention and skin fragility.

Color Changes And Tissue Damage

Diabetic leg ulcers often exhibit distinct color changes, reflecting oxygenation levels, cell death, and healing potential. In the earliest stages, the skin around an ulcer may appear red or dusky, indicating localized inflammation or vascular compromise. Persistent erythema suggests prolonged pressure or friction, which can accelerate tissue breakdown. As the ulcer deepens, the wound bed may take on a yellowish hue due to fibrin and cellular debris, particularly when necrotic tissue begins accumulating.

As circulation declines, the ulcer may darken, turning purple or black due to ischemia. This occurs when oxygen supply becomes severely restricted, leading to cell death and the formation of dry eschar. Unlike moist necrosis seen in infected wounds, dry eschar is leathery and adherent, sometimes serving as a protective barrier against bacteria. However, extensive ischemia can cause tissue loss beyond the superficial layer, exposing underlying structures such as tendons or bone.

Signs Of Infection

Diabetic leg ulcers are highly vulnerable to infection due to impaired healing and reduced immune function. One of the earliest signs is increased wound drainage, often accompanied by a change in fluid consistency and color. Clear or slightly yellow exudate may become thicker, green, or foul-smelling, signaling bacterial overgrowth. Infected wounds may also show signs of cellulitis, where the surrounding skin becomes red, swollen, and warm.

As infection progresses, systemic symptoms such as fever, chills, or elevated blood sugar levels may develop, indicating a more serious complication like cellulitis or osteomyelitis. The wound may deteriorate further, with necrotic tissue forming as bacteria invade deeper layers. A sudden increase in pain—despite preexisting neuropathy—can be a warning sign of advancing infection, as can pus or an unpleasant odor. If untreated, infections can spread rapidly, increasing the risk of sepsis or the need for surgical intervention.

Tips For Daily Care

Proper wound management is essential for preventing complications and promoting healing. Cleansing the ulcer with a mild, non-irritating solution such as sterile saline or an antimicrobial wound cleanser helps maintain hygiene. Harsh chemicals like hydrogen peroxide or iodine should be avoided, as they can damage healthy tissue and slow healing. After cleansing, applying a moisture-balanced dressing supports tissue repair while preventing excessive dryness or maceration. Hydrocolloid, foam, or alginate dressings may be used depending on wound exudate levels.

Daily foot and leg inspections help detect early signs of deterioration. Checking for pressure points, callus formation, or skin texture changes can identify areas at risk for ulceration. Moisturizing intact skin, particularly on the lower legs and feet, minimizes cracks that could allow bacteria to enter. Wearing well-fitted, cushioned footwear and offloading pressure from affected areas reduce mechanical stress on wounds. Regular healthcare monitoring, including vascular assessments and debridement when necessary, further improves outcomes.

When To Seek Professional Attention

Certain warning signs require medical intervention. A wound that fails to improve after two weeks, despite proper care, may indicate underlying complications such as poor circulation or infection. Increasing redness, swelling, or warmth around the ulcer suggests spreading inflammation that could cause severe tissue damage if untreated. A foul odor or thick, discolored drainage often signals bacterial colonization.

Sudden changes in sensation, such as increased pain or new numbness, warrant immediate evaluation, as they may indicate nerve involvement or worsening ischemia. If the ulcer deepens to expose tendons or bone, the risk of osteomyelitis rises significantly, requiring advanced treatment. Systemic symptoms such as fever, chills, or unexplained fatigue necessitate urgent medical care to prevent life-threatening complications. Early intervention, including wound debridement, infection control, and vascular assessment, improves healing outcomes and reduces the likelihood of severe interventions such as amputation.