Lower Extremity Ulcers: Venous, Arterial, and Lymphatic
Venous ulcers
Typically at the medial malleolus and gaiter region: shallow, irregular, moist, heavy exudate, with edema, hemosiderin staining, lipodermatosclerosis, and varicosities. Pain eases with elevation. Compression is the cornerstone once the ABI confirms safe arterial flow; add elevation, exercise, and moisture-balanced dressings.
Arterial ulcers
Distal (toes, lateral malleolus, metatarsal heads), punched out, pale, dry, minimal exudate, with hairless shiny skin, cool feet, weak pulses, and pain worse with elevation and relieved by dependency. Care is revascularization first, protection from trauma, moisture balance, and no compression. A stable, dry eschar on an ischemic limb is often left intact.
Mixed disease
Venous and arterial features coexist; address the arterial component first. Compression may be used with caution at ABI 0.8-1.3, modified at 0.5-0.8, and withheld below 0.5. A falsely high ABI above 1.3 in diabetes or renal disease suggests calcified, non-compressible arteries; use toe brachial index instead.
Lymphatic and lymphovenous ulcers
Massive edema, hyperkeratosis, papillomatosis, lymphorrhea, and fibrosis (positive Stemmer sign). Management is complete decongestive therapy: skin care, manual lymphatic drainage, multilayer bandaging, exercise, and vigilance for cellulitis.
Traps
- Applying compression without an ABI.
- Assuming every leg ulcer is venous.
- Accepting one ABI as definitive in long-standing diabetes.
- Using stockings alone instead of multilayer bandaging for active ulceration.
Rule of thumb
ABI under 0.8 means no compression; wrap with caution from 0.8 to 1.3. An ABI of 0.6 with a weeping medial ankle ulcer indicates mixed disease: modified, reduced compression only under close supervision, with the rationale documented.