Vascular Ulcer

What is a vascular ulcer?

Vascular ulcers are wounds on your skin that develop because of problems with blood circulation. They are most common on your limbs — especially your lower legs and feet — but can also develop elsewhere on your body. These wounds can take a very long time to heal and may need specialized treatment, including surgery.

Vascular ulcers can have two different causes. One is from poor circulation in your arteries, which provide nutrients and oxygen to the body. The other type of vascular ulcer is caused by poor circulation in your veins, which takes blood and waste products from the body and returns them to the heart. The most common type of vascular ulcer is a venous ulcer.

How common are vascular ulcers?

Vascular ulcers are very common, especially as people age. About 1% of adults in the U.S. have a vascular ulcer. For adults over the age of 65, it can be between 3% and 5%.

How does a vascular ulcer affect my body?

Vascular ulcers can have several negative impacts on your life. These include:

• Increased risk of infection. Your skin is a protective barrier that keeps germs out, and a vascular ulcer is a way that germs can bypass that barrier.
• Sepsis. If an infection isn't treated, it can spread and lead to an extremely deadly condition called sepsis. This is when your body reacts so strongly to a major infection that your immune system begins to damage different parts of your body itself.
• Gangrene. Infections — or the lack of blood flow that caused the ulcer in the first place — can cause cells in nearby tissue to die. This can cause gangrene, which will spread and ultimately be fatal if not treated.
• Pain and limited movement. Vascular ulcers can be very painful. Depending on their location, they can keep you from working, resting or doing things you usually enjoy. Because physical activity improves circulation, a painful vascular ulcer can keep you from moving, making the ulcer even worse.

What are the symptoms of a vascular ulcer?

The symptoms of a vascular ulcer depend on what caused it. It's common for multiple causes to happen at once because so many underlying conditions for different types of ulcers are related.

Stasis ulcer symptoms

The following symptoms are often present before venous ulcers form.

• Legs cramp and swell.
• Skin becomes thick or hard and changes to dark colors, usually red, purple or brown.
• Tingling and itching of the affected area (this is called stasis dermatitis).
• Varicose veins are a common sign of developing vein problems.

Stasis ulcers tend to have these symptoms:

• Ulcers tend to form near the ankle.
• The ulcers are shallower and may be red with a yellow layer covering them.
• Ulcers have irregular shapes and the edges are uneven.
• The area around the ulcer can be shiny and the skin may look stretched thin. The area is often warmer than skin further away.
• The ulcers are painful and may bleed or ooze. If they’re infected, they may have a foul smell and ooze pus.

Arterial ulcer symptoms

The following symptoms tend to happen before an arterial ulcer forms.

• The skin near the wound is shiny and dry. It may also look stretched or thin.
• Hair loss in the affected limb or near the wound because of lack of blood flow.
• You may have limited blood flow when you lay down or raise your feet up. This can cause your feet to become pale or feel cooler, and your leg or foot may ache when raised up or when you lay down. (Letting your leg dangle can make the aching stop. Your leg or foot may also turn red from restored blood flow.)

Arterial ulcers tend to have the following symptoms:

• Wounds tend to start on parts of your body furthest from your heart, especially on and between your toes.
• Wounds appear in darker colors, especially red, yellow, gray and black.
• Wounds are deeper and you may be able to see muscles or tendons.
• The edges around the wound are raised or look like they are pushed outward.
• Wounds don’t bleed and may not hurt.

Who do vascular ulcers affect?

Vascular ulcers tend to happen to older people or those who have certain health problems, especially problems related to the heart and circulatory system. The related conditions include:

• Diabetes.
• Obesity.
• Peripheral vascular diseases (either peripheral artery disease or peripheral venous disease).
• Cardiovascular (heart) disease.
• High blood pressure (hypertension).
• Smokingand using tobacco products.

Vascular ulcers can also happen when something other than a disease or condition disrupts blood flow. Examples of this include:

• Injuries. Bone fractures, burns or muscle injuries can damage nearby blood vessels, leading to circulation problems.
• Prolonged standing. Prolonged standing, especially in one spot without moving, such as cashiers, bakers, or restaurant staff, can develop a pooling of venous blood in their legs. If the valves in the veins don’t work well, the blood may not adequately return to the heart. This puts too much pressure on your veins, which causes them to enlarge, leading to varicose veins. The fluid then leaks out of the veins and into the surrounding soft tissues, causing swelling. Blood and protein follow that fluid into the soft tissue and cause color changes or a brownish discoloration in your calves, especially the inner calf. This can be itchy and cause dry or cracked skin, which can be a way for bacteria to enter and cause cellulitis or venous stasis ulcers.
• Family history. Strong family history can also predispose someone to have vascular ulcers.

What causes vascular ulcers?

Vascular ulcers can typically be grouped by their cause. However, it's common for multiple conditions to cause an ulcer. An example of this is how diabetes can cause vascular ulcers.

• Stasis ulcers. Caused by vein problems, these make up the majority of vascular ulcers. These are most common in your legs and feet as you age and happen because the valves in your leg veins can’t do their job properly. This means they can’t stop blood — which should be headed upward to your heart — from being pulled down by gravity. As a result, the excess blood in your legs and feet puts too much pressure on the blood vessels, which leak and burst. Over time, this can ulcers to develop.
• Arterial ulcers. These are also called ischemic (iss-keem-ick) ulcers. These happen because of limited blood flow to an affected area, a problem called ischemia (iss-kee-me-uh). The affected body part, usually a limb, slowly dies because of a lack of blood flow.

How is a vascular ulcer diagnosed?

A healthcare provider can quickly diagnose a vascular ulcer by examining it. They will look closely at the ulcer and may feel the area around it, checking for specific symptoms.

However, your provider will also want to diagnose whatever caused the ulcer. Parts of their examination of the wound will help them do this, but they will also order certain tests to help them fully understand the cause, mainly because vascular ulcers can have multiple causes and many of those causes can be connected.

What tests will be done to diagnose the cause of a vascular ulcer?

Your healthcare provider or a specialist will do the following:

• Blood pressure. Your provider will take the blood pressure on your arm. They’ll also take a blood pressure reading in your legs to see if there’s a difference between the two. This is called the ankle-brachial index (ABI) test.
• Listen to your heart and check your pulse. Listening to your heart and breathing sounds, your provider may find evidence of an underlying heart problem that could be contributing to vascular ulcers. They’ll also feel for a pulse in your lower legs and feet, which are called peripheral pulses. Depending on the strength of the peripheral pulse — or if it can’t be felt at all — your provider can narrow the focus of their diagnosis.
• Blood testing. Blood tests can help a provider make a diagnosis or help them determine how to treat the ulcer going forward. One test, in particular, is the A1C hemoglobin test, which can determine if you have diabetes, and its severity if diabetes is found.
• Imaging. Your provider may order imaging tests to examine not just the wound itself but also the blood flow around it. They may also order imaging on major arteries and veins elsewhere in your body, as these can also show signs of problems related to a vascular ulcer. These tests can include X-rays, MRIs, CT scans and ultrasounds.

Can vascular ulcers be cured?

In many cases, it's possible to heal a vascular ulcer. However, the likelihood of healing the ulcer depends on how severe it has become, so early treatment of vascular ulcers is critical to a good outcome.

It's also essential to address the underlying problem that caused the ulcer. Your provider will likely recommend not just care for the ulcer but also for underlying health problems you have. Some of their recommendations will involve lifestyle changes that will help reduce your risk of another ulcer. The changes should also help improve your quality of life overall.

How is a vascular ulcer treated?

Vascular ulcers may be treated in a variety of ways, depending on how severe they are and what caused them.

Medications that may be used include:

• Antibiotics. These can treat an infection. In some cases (such as after surgery), they may be given to prevent an infection from setting in.
• Topical gels and ointments. These can help remove dead or infected tissue, improve circulation to the affected area, prevent infection and help speed up wound healing.
• Medications to treat the underlying problem. Controlling your blood pressure and cholesterol, quitting tobacco and managing your blood sugar can all help wounds heal.
• Pain medications or numbing agents. Vascular ulcers and some of the treatments used for them can be painful. It's common for pain or numbing medications to be used during your treatment.

Bandages and different types of wearable items are commonly used to treat vascular ulcers. These should only be used as your healthcare provider directs you. Misusing these can make a vascular ulcer much worse rather than better.

• Bandaging. Covering the ulcer with a protective bandage can help keep it from being infected. Certain types of bandages may also be medicated, helping speed up wound healing.
• Compression garments: These include socks, stockings and various other items. By applying pressure to the entire leg, swelling can be limited or stopped. This is commonly used with venous ulcers and helps keep blood from pooling in the legs and feet.
• Specialized shoes, socks or orthotic devices. Many vascular ulcers, especially diabetic ulcers, are caused by simple wear and pressure. Normally, feeling pain from this would cause you to change how you walk, easing the damage to the affected area. However, this doesn't happen with diabetic ulcers because these are often caused by a partial or total loss of feeling in the feet.

Advanced methods for treating vascular ulcers, especially ones that are larger or are taking longer to heal, may also be used.

• Revascularization. Vascular ulcers may happen because of blockages in crucial blood vessels. Revascularization treatments attempt to remove the blockage, helping existing wounds here and preventing new ones from happening.
• Surgery. For wounds that are infected or that are larger and harder to heal, surgery may be used. A surgeon can debride a vascular ulcer to remove dead or infected areas of the wound and perform surgery to make it easier for the wound to heal. This can include skin grafts and other types of reparative techniques. (In the case of advanced gangrene or very severe vascular ulcers, it’s sometimes necessary to amputate part of a foot or leg. This option is meant to save lives and avoid even worse complications. Unfortunately, for people with diabetes, the risk of developing gangrene in the feet is 30 times higher than it is for the average population.)
• Prescribed walking. Physical activity, especially when done with medical guidance, can help improve circulation and help with preventing new vascular ulcers from forming.
• Hyperbaric oxygen therapy. The normal oxygen level around you is 21%. Hyperbaric oxygen therapy places you in a chamber that has 100% oxygen concentration and higher atmospheric pressure. These conditions can speed up wound healing, especially for vascular ulcers.
• Debridement. Dead and infected tissue in and around a vascular ulcer can slow recovery and lead to gangrene and other dangerous complications. Debriding the area removes the dead or infected tissue so that only healthy tissue remains.

How can I manage my symptoms?

If you are at risk of developing a vascular ulcer, there are things you can do to protect your health and avoid a vascular ulcer. This is especially true if you have diabetes or any other condition that means you have limited or no feeling in your feet.

• Check yourself. Inspect your feet daily, paying particular attention to the areas between your toes, around your ankles, and on the soles of your feet.
• Protect your feet. Guard against foot injuries by wearing shoes and socks that fit correctly.
• Get proper foot care. If you have diabetes, you should see a specialist regularly who can check your feet for any signs of ulcers forming. They can also advise you on how to best care for your feet.
• Manage the underlying conditions. By taking care of your blood pressure, cholesterol, blood sugar, weight and more, you can help prevent ulcers.

If you have a vascular ulcer, your provider can guide you on how to care for it. They will likely advise you on any of the following:

• Keep the wound clean. Use bandages as directed and change them according to the instructions given to you by your provider.
• Rest as directed. If you have a venous ulcer, your provider will likely tell you to elevate your feet to help prevent swelling.
• Take your medications as directed. This is especially true for antibiotics or medications that help with blood pressure, diabetes, high cholesterol and more.

What are the possible complications and side effects of treatment?

Side effects of treatment depend on which treatments are used. Your healthcare provider can explain the possible complications or side effects relevant to you based on your treatment plan.

How soon after treatment will I feel better? / How long does it take to recover from this treatment?

Vascular ulcers can take weeks or even months to heal under normal circumstances. However, if cared for properly — including closely following the treatment plan provided to you — wounds should heal faster than expected. Your provider can tell you what to expect based on your specific wound issue and can help you track your progress along the way.

How can I reduce my risk of developing a vascular ulcer?

There are some things you can do to reduce your risk of developing a vascular ulcer. They can also help improve ulcers you already have.

• Maintain a healthy weight. Obesity is strongly tied to the formation of vascular ulcers and health problems that may also cause ulcers.
• Manage your health issues. This includes high cholesterol, high blood pressure, diabetes and more.
• Get a regular checkup. Many of the issues that can cause a vascular ulcer can be caught during a routine physical, even if they aren't causing symptoms yet. Knowing about a health concern early can help you avoid developing an ulcer.
• Quit tobacco. The use of tobacco and nicotine products is closely tied to an increased risk of several conditions — including high blood pressure and heart disease — that can cause a vascular ulcer.
• Don't delay care. If you develop a wound that is taking longer to heal than expected, see your doctor as soon as possible. They can examine the wound and help you resolve it before it gets even worse.

What can I expect if I have a vascular ulcer?

If you have a vascular ulcer or have had one in the past, you have an increased risk of developing another. Taking care of your health is the best way to delay a new one from forming. If you manage your health, you’re more likely to live longer overall and to have fewer health problems.

Conversely, not taking care of your health makes it more likely that a vascular ulcer — and your overall health — will get worse. In the most severe cases, not taking care of an ulcer and your health can lead to the need for amputation, and it can even lead to conditions that are deadly.

When should I see my healthcare provider?

You should see a primary care provider at least once a year for a physical. This is key to the early detection of health problems, including those that can cause vascular ulcers.

You should also talk to your provider if you have any of the following:

• A wound on one of your legs or feet that is taking longer to heal.
• Symptoms that might mean you are having circulation problems in your legs, especially swelling, pain, color changes or pain that changes or goes away depending on how you hold your leg or foot.
• Pain in your legs that gets better when you rest.

When should I go to the emergency room?

If you have a vascular ulcer, you should go to the emergency room if it becomes infected and you develop certain symptoms.

• Skin turning dark brown or black around the affected area, especially if this involves your toes.
• Fever or chills.
• A bad odor coming from a vascular ulcer.
• If a vascular ulcer starts to ooze or bleed more than before, especially if the fluid coming out is cloudy or yellow.
• If there is swelling, redness or the wound and its surrounding area are warm or hot to the touch.

A note from Cleveland Clinic

Vascular ulcers are generally a sign of an underlying chronic health condition. While these conditions are serious, it is possible to manage them and keep on enjoying your life. Your healthcare provider can offer you guidance, resources and more, all of which can help you do what it takes to keep chronic conditions from interfering with how you want to live your life.