A lot of patients are worried about developing leg ulcers in later life - and that is not surprising. In my work as a vascular surgeon, I have treated thousands of patients with leg ulcers and seen at first hand the problems they cause. An leg ulcer is basically a sore that does not heal up. It is usually found on the lower part of the leg and can start from a very minor injury or even spontaneously.
Leg ulcers are painful and seriously debilitating. They constantly weep fluid and smell horribly. The need for repeated and painful dressing changes limits mobility and often patients end up restricted to their homes and isolated. Ulcers frequently get infected, due to the raw skin. Episodes of infection are very painful and make the ulcer spread wider across the leg.
All things considered, a leg ulcer is high on the list of health problems that are best avoided. We can heal leg ulcers, but this is a long and painful process, requiring intensive and expert pressure bandaging on the leg by a specialist nurse. The cost of dressings and nursing time to the NHS has been estimated at £2 billion per year.
The irony is that most leg ulcers can be prevented before they even start! This might come as a surprise to most readers - how can it be that such a serious problem could go undetected and get so bad that it eventually causes an ulcer?
About 85% of ulcers are caused by problems with 'venous reflux' - that's a medical term for 'backwards flow' in the veins of the leg. The backwards flow is caused by faulty valves in the veins. About a third of the population have some degree of venous reflux - but for most people it is not bad enough to cause a leg ulcer in the short term.
Vein reflux usually causes varicose veins - the bulging unsightly blue veins that stick out on the lower part of the leg and cause aching, discomfort and swelling of the ankles in many patients
One of the problems with venous reflux is that it can be completely invisible to the naked eye - you can have it without noticing varicose veins or any particular problems with the leg, except for damage to the skin around the ankle. The problem can be picked up by scanning the leg with ultrasound to pick up the backwards flow in the vein and the swelling of the blood vessel that usually goes with it.
If the backwards flow is diagnosed and fixed in a timely fashion, then the skin damage at the ankle will improve and not deteriorate into an ulcer. Treatment for venous reflux has made tremendous improvements in recent years - the vast majority of cases can be fixed with a fairly simple procedure using a laser fibre inserted into the vein under local anaesthetic. Once the leaking vein has been sealed shut and the pressure inside it reduces, the ulcer will usually heal up within a couple of months.
Perhaps surprisingly, many family doctors are unaware of the advances in vein treatment that allow specialists to fix vein problems before they create ulcers on the legs. The recent changes in the NHS referral system that restrict vein problems being referred to specialists may have something to do with this - for many doctors these days the NHS 'doesn't do veins', so patients are left to find their own way to access diagnosis and treatment. This is a shame, because the best way to treat a leg ulcer is not to get one in the first place - prevention is a lot easier than cure - and we have excellent techniques to prevent most leg ulcers from happening in the 21st Century.