Lower leg ulcer diagnosis and principles of treatment

What is it about?

Chronic wounds are a huge burden on the individual’s quality of life (QoL) and healthcare system (1–3). Right and early diagnostics of chronic wounds is essential for successful wound management (4, 5); however, there is a dearth of literature describing the outcomes of wound healing related to the timing and accuracy of diagnostics. Chronic lower limb wounds can be divided into six main categories: venous, arterial, mixed venous and arterial, diabetic foot, pressure and atypical ulcers (6, 7). However, more and more wounds are multiaetiological in the clinical setting (8, 9), and one diagnosis does not exclude another. In the clinical setting, it is not unusual to see a patient suffering from arterial and venous insufficiency, and also a wound with an atypical cause (see Figure 1). There are also other reasons for leg oedema than venous insufficiency (see Chapter 5). In our opinion, the definition of a chronic wound is somehow constrained, as some acute wounds can be “chronic or hard to heal” from the beginning. For instance, an acute wound might develop into a chronic wound within some weeks if the patient has arterial or venous insufficiency or other reasons for leg oedema, and this is not considered in the treatment plan from the beginning. In many European countries, individuals with a chronic wound are first seen in primary care by a nurse or by a general practitioner (GP). This poses a huge demand on the respective professionals; they should have enough education and tools to assess the patient and perform the necessary referrals. For instance, if the patient is not recognised to have arterial insufficiency, the referral for revascularisation is delayed and may lead to amputation (10). Additionally, compression therapy should be introduced from the very beginning in every lower leg ulcer, if there are no contraindications. It is widely recognised that GPs might not have sufficient knowledge of leg ulcer assessment and treatment (11). Likewise, nurses and allied health professionals treating lower leg ulcers should be aware of the differential diagnostics and referral pathways so that the individual does not have to self-manage too long, and adequate referrals are done. In response to the lack of uniform diagnostic guidelines in the field of lower leg ulcers, the European Wound Management Association (EWMA) established this working group to gather the best available evidence on the diagnostics of a lower leg ulcer. Focus is on the diagnostics of infection, arterial and venous insufficiency, leg oedema and atypical causes. The one-pager published together with the document aims to be a practical tool to aid for the diagnosis of a lower leg ulcer.

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