Leg ulcers are open wounds on the lower leg that fail to heal on their own within a normal timeframe, typically persisting for weeks or months. They affect roughly 1 in 300 people, and the majority (60% to 80%) are caused by problems with blood flow in the veins. Understanding what type of ulcer you’re dealing with is essential because each type has a different cause, appears in a different spot on the leg, and requires a different approach to treatment.
How Leg Ulcers Form
Most leg ulcers develop because of a circulatory problem. In healthy legs, valves inside the veins push blood back up toward the heart. When those valves weaken or fail, blood pools in the lower legs, building up pressure in the veins. Over time, that sustained pressure damages the surrounding skin and tissue, making the area fragile. A minor bump, scratch, or insect bite can then break the skin, and instead of healing normally, the wound stays open.
This process, called chronic venous insufficiency, doesn’t happen overnight. The skin gives warning signs long before an ulcer appears: small visible veins near the surface, swelling that worsens by evening, itching or a rash around the ankle, and eventually a brownish-orange discoloration caused by iron pigments leaking from damaged blood vessels. The skin may also feel hard or tight, a sign of thickening in the tissue beneath. Recognizing these early changes is the best opportunity to intervene before a wound develops.
The Three Main Types
Venous Ulcers
Venous ulcers are the most common type. They typically appear on the inner ankle or the lower leg between the ankle and calf, sometimes called the “gaiter” area. These wounds tend to be shallow with irregular borders and a red wound bed, often covered in a yellowish film. They produce a moderate to heavy amount of fluid, which can soak through dressings and sometimes cause odor. The surrounding skin is usually swollen, discolored, and may feel itchy or achy. Pain often worsens when standing and improves when the legs are elevated.
Arterial Ulcers
Arterial ulcers come from the opposite problem: not enough blood reaching the legs rather than too much pooling there. Narrowed or blocked arteries starve the tissue of oxygen, and the resulting wounds look quite different. They appear on the toes, feet, or bony points rather than the lower leg. The wound has clean, well-defined edges, a pale or blackened base, and produces very little fluid. The skin around an arterial ulcer is thin, shiny, and cool to the touch, often with little to no hair. Pulses in the foot may be weak or absent.
Neuropathic (Diabetic) Ulcers
People with diabetes can develop ulcers caused by nerve damage. When sensation is lost in the feet, pressure injuries from walking or ill-fitting shoes go unnoticed. These wounds almost always form on the sole of the foot, often at sites where calluses have built up. They tend to look like a puncture or a round hole with smooth, well-defined edges, sometimes described as “punched out.” Because the person can’t feel pain in the area, these ulcers can grow significantly before they’re even noticed.
Symptoms and Warning Signs
Not every leg wound is an ulcer, but certain patterns should raise concern. With venous ulcers, the most common complaints are itching (with or without a visible rash), a dull aching pain in the lower leg, swelling in the feet and ankles that appears by evening, and night cramps. The wound itself is often surrounded by stained, hardened skin.
Watch for signs that a wound has become infected: increasing redness, warmth, or swelling around the edges, foul-smelling discharge, fever or chills, and pain that intensifies enough to interfere with sleep or daily activities. Infection can spread to the deeper tissue or bone if left untreated, so these changes need prompt attention.
How Leg Ulcers Are Diagnosed
Figuring out the cause of a leg ulcer determines the treatment, so diagnosis starts with checking blood flow. The most common test involves comparing blood pressure at the ankle to blood pressure in the arm, producing a ratio called the ankle-brachial pressure index. A ratio above 1.0 suggests the arteries are healthy. Ratios between 0.5 and 0.8 indicate moderate arterial disease, and anything below 0.5 signals severe blockage. This distinction matters because compression therapy, the primary treatment for venous ulcers, can be dangerous if significant arterial disease is present.
Beyond the pressure test, the appearance and location of the wound, the condition of the surrounding skin, and your medical history (varicose veins, blood clots, diabetes, smoking) all help narrow down the type.
Treatment for Venous Ulcers
Compression is the cornerstone of venous ulcer treatment. Wrapping the lower leg firmly counteracts the pooled blood pressure that caused the ulcer in the first place, allowing the tissue to heal. The target is around 40 mmHg of pressure at the ankle, which is considered the gold standard. This level of compression is most often achieved with multi-layer bandage systems applied by a nurse or healthcare professional.
For people who find bandages bulky or difficult to manage, two-layer compression stocking systems have been developed that deliver the same 40 mmHg when both stockings are worn together. Single-layer compression stockings typically deliver lower pressure (between 14 and 35 mmHg depending on the class) and may not be sufficient for active ulcers, though they play an important role in preventing recurrence after healing.
With consistent compression therapy, venous leg ulcers often heal within six months. The wound itself is covered with dressings chosen based on how much fluid it produces. Very wet wounds do best with absorbent dressings like foams or alginates that draw excess moisture away and prevent the surrounding skin from breaking down. Drier wounds benefit from more moisture-retaining options like hydrogels or hydrocolloids. The goal in all cases is keeping the wound moist enough to heal without waterlogging the healthy skin around it.
Treating Arterial and Diabetic Ulcers
Arterial ulcers require restoring blood flow, which may involve procedures to open or bypass blocked arteries. Compression is not appropriate here because the issue is too little blood supply, not too much pressure. Treatment focuses on improving circulation and protecting the wound from further damage.
Diabetic foot ulcers are managed by relieving pressure on the wound (often with specialized footwear or casts), controlling blood sugar, and treating any infection. Because nerve damage masks pain, regular foot checks become a daily habit for anyone at risk.
Why Recurrence Is So Common
One of the most frustrating aspects of leg ulcers is how frequently they come back. Among people whose venous ulcers have healed, 22% develop a new ulcer within three months, 57% within a year, and 78% within three years. These numbers underscore that healing the wound is only half the battle. The underlying vein problem doesn’t go away when the skin closes.
Preventing recurrence typically means wearing compression stockings every day, staying physically active to keep blood circulating, elevating the legs when resting, and maintaining a healthy weight to reduce strain on the venous system. Skipping compression even briefly increases the risk of a new ulcer forming. For some people, procedures to treat damaged veins (such as varicose vein surgery or ablation) can reduce recurrence by addressing the root cause of the venous pressure.
Living With a Leg Ulcer
Leg ulcers affect more than the skin. The heavy fluid discharge can cause persistent odor, which leads many people to withdraw from social situations. Pain and disrupted sleep are common. Limited mobility and the time commitment of regular dressing changes can interfere with work and daily routines. These quality-of-life impacts are real and well documented, and they’re worth discussing openly with whoever is managing your wound care.
Healing takes patience. Even with optimal treatment, venous ulcers that have been present for months before treatment begins take longer to close. Keeping compression on consistently, attending regular wound assessments, and protecting the legs from injury all improve outcomes. The earlier a wound is treated, the faster and more reliably it heals.