### Venous Leg Ulcers: When Circulation Fails

Venous leg ulcers represent the most common type of leg wound, affecting up to 1% of the adult population and accounting for 70-90% of all leg ulcers. These wounds develop when the venous system in the legs fails to adequately return blood to the heart, creating a cascade of problems that can lead to chronic, non-healing wounds.

The venous system in the legs must work against gravity to return blood to the heart. This is accomplished through a series of one-way valves that prevent blood from flowing backward, assisted by the pumping action of leg muscles during walking. When these valves become damaged or incompetent, blood begins to pool in the lower legs, creating a condition called venous insufficiency.

Chronic venous insufficiency leads to increased pressure in the leg veins, which causes fluid to leak out into surrounding tissues. This creates the swelling, or edema, that's characteristic of venous disease. The leaked fluid contains proteins and other substances that trigger inflammation and can directly damage skin and underlying tissues.

Over time, the chronic inflammation and fluid accumulation lead to changes in the skin and subcutaneous tissues. The skin may become thick and hardened, take on a brownish discoloration, and develop areas of scarring called lipodermatosclerosis. These changes make the skin more fragile and prone to breakdown with minor trauma.

Venous leg ulcers typically develop on the inner aspect of the lower leg, often just above the ankle. They tend to be shallow but can be quite large, with irregular borders and a weeping, infected appearance. The surrounding skin often shows the characteristic changes of chronic venous disease.

The key to healing venous leg ulcers is addressing the underlying venous insufficiency that created the wound. Compression therapy, which applies external pressure to counteract the high venous pressures, is the cornerstone of treatment. Compression can be achieved through various means, including compression stockings, bandages, or specialized devices.

The challenge with compression therapy is that it must be applied and maintained consistently to be effective. Many patients find compression uncomfortable, especially initially, and compliance can be a significant issue. Education about the importance of compression and gradual introduction of compression levels can help improve acceptance.

In addition to compression, wound care for venous ulcers focuses on managing infection, controlling drainage, and protecting the wound from further trauma. Advanced wound care products may be used to optimize the healing environment, but these are typically not effective without adequate compression.

Some venous ulcers may benefit from interventions to improve venous function, such as surgery to repair or bypass damaged veins, or minimally invasive procedures to close off incompetent veins. These treatments can help prevent recurrence of ulcers after healing is achieved.