More than 70% of leg ulcers are caused by venous diseases, and their prevalence increases with age. Venous leg ulcers account for most chronic lower-limb wounds observed in primary care, underscoring the need for early diagnosis and targeted management.

During the wound care session at the National Days of General Medicine (JNMG 2025), Claire Jacquin-Porretaz, MD, stressed the importance of determining whether an ulcer is venous, arterial, or mixed before applying compression.

She noted that venoactive drugs provide only limited benefits and highlighted an updated digital wound care module in Dermagic, a clinical support platform that helps clinicians assess ulcers and select appropriate dressings.

Disease Profile

Leg ulcers are common and occur frequently in older adults. Most cases are associated with venous insufficiency. Approximately 10% are arterial, and approximately 20% have combined venous and arterial features. Mixed etiology becomes more frequent with age.

Identifying the underlying cause is critical for treatment planning. Patient interviews often offer early clues. A history of venous surgery, pulmonary embolism, or symptoms such as heavy legs indicate venous disease. Intermittent claudication and risk factors, such as diabetes or smoking, suggest arterial involvement.

Digital Tool

Dermagic is both an association and an open-access platform that supports dermatology practice. Developed by clinicians in France, it was designed as a practical point-of-care resource for managing common skin conditions.

The platform includes more than 600 disease summaries, 300 medical device sheets, and nearly 100 treatment guides for generating standard prescriptions. Its updated wound care module supports ulcer assessment and helps clinicians code technical procedures, offering structured guidance for settings where specialist dermatology support may be limited.

Clinical Assessment

Clinical examination should begin with checking pulses in the lower limbs — femoral, popliteal, dorsalis pedis, and posterior tibial — to determine whether the ulcer is venous or arterial.

Clinicians should also evaluate ulcer size, number, and location, examine the wound edges and surrounding skin, and assess its effect on mobility.

Signs of venous disease include varicose veins, stasis eczema, and capillaritis features, such as ochre dermatitis, white atrophy, and reticular veins. Arterial insufficiency is more likely when pulses are absent and the skin is shiny, pale, cool, and slow to regain color.

Arterial ulcers typically occur distally and may appear necrotic. “The wounds are more often distal and have a necrotic appearance,” Jacquin-Porretaz said. The surrounding skin is “smooth, shiny, and hairless,” and these ulcers are usually deeper.

Screening Clues

Initial screening questions can help guide diagnosis. A “yes” to any of the following suggests a high likelihood of a predominantly venous ulcer:

• History of spider veins, varicose veins, venous surgery, phlebitis, or pigmentation such as ochre dermatitis
• Palpable pulses
• Visible edema
• Warm foot
• Ulcer located near the malleoli

Arterial ulcer is more likely if any of the following conditions are present:

• Absence of dorsalis pedis and/or posterior tibial pulses
• Cold foot
• Rest pain that improves when the leg is lowered
• Deep, excavated or “digging” ulcer
• Calf pain or discomfort with walking
• Capillary refill that takes more than 3 seconds
• Necrotic (black) tissue
• Associated toe sores or toe ulcers

To confirm the diagnosis, Doppler ultrasound is required to assess arterial flow. This should include measurement of the ankle-brachial index (ABI). An ABI > 1.3 may indicate medial arterial calcification, often seen in diabetes, and may require a toe pressure measurement.

ABI then guides management, particularly compression decisions. Values between 0.9 and 1.3 indicate a venous ulcer, and full compression can be applied.

An ABI < 0.6 suggests an arterial ulcer, making compression contraindicated. For ABI values between 0.6 and 0.8, the ulcer is mixed, and compression should be reduced to account for the arterial component.

Antibiotic Use

Treatment should not routinely rely on antibiotics; the dermatologist reminded attendees. “Studies have shown that more than two thirds of patients with chronic leg ulcers have received antibiotic therapy in the last 6-12 months. Antibiotic therapy was often unjustified and prescribed intermittently.”

Antibiotics should be used only when there are clear signs of infection, such as abscess, bacteremia, sepsis, or documented osteomyelitis in a febrile patient. Heavy drainage, fibrin, or foul odor alone does not justify systemic therapy. “In this case, local management should be adapted.”

Wound Preparation

Wound preparation before compression began with cleansing using water and pH-neutral soap. “Don’t hesitate to tell your patients to wash their own wounds in the shower. This makes it easier to remove the dressing and soften the scabs around the ulcer. This washing method is suitable for all types of wounds.”

Cleansing softens the tissue and facilitates debridement. Debridement removes nonviable tissue, such as necrotic, devitalized, or fibrinous material, and can be performed when there are no contraindications and after local anesthesia, ideally with lidocaine spray. “Debridement is essential for ensuring healing. It can save the patient weeks,” Jacquin-Porretaz said.

Debridement is not recommended for peripheral artery disease, necrotizing angiodermatitis, malignant wounds, or advanced pressure ulcers. “In patients with nonrevascularized arterial disease, debridement is not recommended, as vascular resources are insufficient to ensure healing.”

Team Collaboration

Nurses may hesitate to perform thorough cleaning or debridement. Effective wound care requires close collaboration between doctors and nurses. Clinicians should remain available, offer guidance, and provide training when necessary. Online tutorials can also help reinforce skills.

Dressing selection depends on the amount of exudate and stage of healing. Because many products are available, the wound-care module on the Dermagic platform, a clinician-developed dermatology support tool, helps users choose an appropriate dressing, along with compression materials, cleansing supplies, and analgesic options.

At the end of the selection process, the tool generated personalized prescriptions. “The prescription intended for the pharmacy is to be copied and pasted into your computer system. Another, intended for the nurse, contains the entire protocol already written,” said Anne-Laure Messagier, PhD, from the Dermatology Department, CHU Pierre Zobda-Quitman, Fort-de-France, Martinique, and cofounded the Dermagic platform with Jacquin-Porretaz.

Compression Therapy

Compression is essential for venous ulcers, and multilayer dressings are now recommended as first-line therapy, Jacquin-Porretaz said. “The advantage is that they can be worn day and night, which improves treatment adherence. We observe a reduction in edema within a few days.” Dressings may be changed daily or extended up to 7 days, depending on exudate and swelling.

For mixed ulcers with an arterial component (ABI, 0.6-0.9), compression must be adjusted using short-stretch bandages. However, this approach requires close monitoring. Patients should also be encouraged to remain active.

The correct technique is critical. “Compression bandages should be applied in the morning upon waking. The foot should be at a 90-degree angle. Start at the base of the toes and work upward with progressively increasing pressure until two fingers are below the popliteal fossa. It is essential to also apply the bandage to the heel; otherwise, the compression will be ineffective.”

Follow-up ensures that the bandage remains secure and comfortable. “Most often, the bandages aren’t tight enough.” Excessive pressure may cause discomfort or skin injury, particularly along the tibial crest. “In such cases, padding should be applied.”

Venoactive drugs may relieve symptoms but provide modest benefits.

A recent literature review revealed that evidence supporting the use of venoactive drugs in venous leg ulcers is limited and that they should not be recommended for routine use.

In addition to compression therapy, a surgical approach should be considered. Several studies have shown that early surgical treatment of venous disease can improve healing and help prevent recurrence. “Don’t hesitate to consult a vascular surgeon.”

The management of arterial ulcers relies primarily on urgent surgical intervention, such as bypass, angioplasty, or thrombectomy. Vasodilator therapy can also be prescribed. Once the limb is revascularized, debridement can be safely performed.

To support wound healing in both arterial and venous ulcers, patients should be encouraged to remain physically active, including walking or cycling. Physiotherapy and gait rehabilitation may also be beneficial.

This story was translated from Medscape French edition.