Venous Leg Ulcers: Why They Won't Heal, and How They Are Treated

Written and medically reviewed by Dr. Prashanth J V MBBS, MS (General Surgery), FMAS, FISCP, DMAS

Consultant Laparoscopic & Laser Surgeon · 27+ years in practice · Karnataka Medical Council Reg. No. 41048 · Last reviewed: 5 October 2026

✓ Medically Reviewed

A venous leg ulcer is one of the most frustrating problems a patient can have. A small wound near the ankle, sometimes from nothing more than a scratch, simply refuses to close. Dressings are changed for weeks, sometimes months, and it may heal only to break down again.

The reason is almost always the same. The wound is a symptom of high pressure in the leg veins, and it will struggle to heal for as long as that pressure is not dealt with. Once you understand why, the treatment makes sense.

What Is a Venous Leg Ulcer?

A venous leg ulcer is an open wound on the lower leg, usually in the area just above the inner ankle, that has not healed within two weeks. It is the most advanced stage of chronic venous disease, stage C6 on the international CEAP scale, and it typically follows years of untreated varicose veins or venous insufficiency.

When the valves in the leg veins fail, blood refluxes down the leg and pressure in the veins near the ankle stays high even when you walk. Over time this forces fluid and blood cells into the surrounding tissue. The skin becomes stained brown, itchy and inflamed, then hard and tight. Skin in that state has poor nourishment and heals badly, so a minor injury becomes an ulcer.

Is It Venous, Diabetic or Arterial?

Not every leg wound is venous, and the distinction matters because the treatment differs, and compression that heals a venous ulcer can harm a leg with poor arterial supply.

Many people have more than one problem. Diabetes is common, and a venous ulcer in someone with diabetes or arterial disease needs both conditions managed. This is why assessment always comes before compression.

How a Leg Ulcer Is Assessed

• Examination of the leg and the wound, including its size, depth, edges and any signs of infection.
• Ankle-brachial pressure index (ABPI). A simple blood-pressure comparison between ankle and arm that checks the arterial supply is good enough for compression to be safe.
• Duplex ultrasound of the veins. This identifies which veins are refluxing and whether the deep veins are healthy, which decides whether the vein can be treated.
• Blood tests where appropriate, including blood sugar, because undiagnosed or poorly controlled diabetes slows healing.

Treatment: Three Things Working Together

1. Compression. Firm, graduated compression, usually multi-layer bandaging while the ulcer is open, is the foundation of healing. It counteracts the high vein pressure, reduces swelling and allows the skin to recover. It must be applied correctly and only after the arterial circulation has been checked.

2. Wound care. The ulcer is cleaned and dressed to keep it moist and protected, with any infection treated. Dressings support healing, but on their own they cannot overcome the vein pressure that caused the ulcer.

3. Treating the leaking vein. This is the step most often missed. When Duplex shows reflux in the superficial veins, closing them with endovenous laser ablation or foam sclerotherapy removes the cause. The procedure is done through a needle puncture under local anaesthesia, and can usually be performed while the ulcer is still open.

What the Evidence Shows

Two major randomised trials changed how venous ulcers are managed. The EVRA trial, published in the New England Journal of Medicine in 2018, compared compression plus early endovenous ablation with compression plus ablation deferred until after healing. Early ablation healed ulcers faster, with a median healing time of 56 days against 82, and gave patients more ulcer-free time over the following year.

Earlier, the ESCHAR study, published in The Lancet in 2004, found that adding treatment of superficial vein reflux to compression did not speed healing in that trial, but significantly reduced how often ulcers came back. Taken together, the message is clear: treat the vein, and treat it early. NICE guidance accordingly advises referral to a vascular service for anyone with an active or healed venous leg ulcer.

Preventing the Ulcer Coming Back

• Have the refluxing vein treated if the scan shows it is suitable
• Continue wearing compression stockings after healing, as advised
• Walk daily and elevate your legs when resting
• Moisturise the skin of the lower leg and protect it from knocks
• Keep blood sugar and weight under control
• Seek advice early if the skin starts to itch, darken or break again

When to Seek Care Urgently

See a doctor the same day if the skin around the ulcer becomes increasingly red, hot and swollen, if you develop a fever, if the wound is enlarging quickly or turning black, if pain is suddenly much worse, or if it bleeds heavily. Sudden calf pain with swelling, or breathlessness, needs emergency care.

Getting Assessed

If you have a wound near the ankle that has not healed in two weeks, or one that keeps coming back, an assessment that includes a Duplex scan and an ABPI is the right next step. For more on how venous disease is staged and treated, see our complete guide to varicose vein treatment in Bangalore, and our article on the warning signs that varicose veins need attention.

Dr. Prashanth J V

MBBS · MS (General Surgery) · FMAS · FISCP · DMAS · Advanced Laser Vein Training, AVIS Vascular Centre · KMC Reg. 41048

This article is general health information and does not replace an individual consultation, examination and Duplex ultrasound.