Skin Ulcer

A skin ulcer is an open wound that develops when poor blood circulation prevents injuries from healing properly, often affecting the legs, feet, back, and hips, with older people being more commonly affected.

Table of contents

• What is a skin ulcer?
• Signs and symptoms
• Causes and risk factors
• Different types of skin ulcers
• How doctors identify skin ulcers
• Treatment approaches
• Possible complications
• Prevention and self-care

What is a skin ulcer?

A skin ulcer is an open sore that develops on the skin’s surface when tissue breaks down due to poor blood flow. Good blood circulation is essential for wound healing, but when blood flow problems exist, even minor injuries cannot heal properly and may develop into ulcers over time.^[1]

These wounds can appear on various areas of the body, though they most commonly affect the legs. Studies show that up to 3 in 1,000 people have active leg ulcers. Skin ulcers can also develop on the feet, back, hips, mouth, lips, and bottom.^[1][2]

In medical terms, an ulcer involves the complete loss of the outer skin layer (called the epidermis) and often affects deeper layers including the dermis (the layer beneath the epidermis) and sometimes even the fat tissue below.^[3]

Skin ulcers are more common in older people and can take a very long time to heal. If left untreated, they can become infected and lead to serious medical complications, including the spread of infection throughout the body.^[1][2]

Signs and symptoms

Skin ulcers typically appear as round, open sores on the skin. In the early stages, you may notice skin discoloration in the affected area. The skin might look red and feel warm. If you have darker skin tones, the area may appear shiny or blue.^[1]

As the ulcer worsens, it begins to look like a crater with raised and thick outer borders. The wound might weep clear fluid or blood.^[1] In severe cases, ulcers can become deep wounds that extend through muscle tissue, leaving bones and joints exposed.^[2]

Additional symptoms may include:^[1][2]

• Swelling of the skin near the ulcer
• Redness and tenderness around the affected area
• Itchiness
• Pain or discomfort
• Dry or flaky skin around the ulcer
• Changes in skin texture
• Hair loss near the ulcer
• Yellow or green discharge (indicating infection)
• Foul odor coming from the area
• Scabbing

Ulcers are usually classified by how long they take to heal. Those that heal within 12 weeks are typically considered acute, while those lasting longer are classified as chronic.^[3] Chronic ulcers may cause constant pain both day and night, and symptoms often worsen once the wound becomes infected.^[3]

Causes and risk factors

Skin ulcers develop when there is a problem with blood circulation. Poor blood flow prevents wounds from healing and causes tissue damage over time.^[1]

Diabetes is a major cause of skin ulcers. This disease causes high blood sugar levels, which over time can lead to nerve damage called peripheral neuropathy. When you have neuropathy, you may lose the sense of touch in your feet and legs. Since you cannot feel pain or pressure, you won’t notice injuries on your legs or feet. High blood sugar also slows down wound healing, allowing untreated injuries to turn into skin ulcers.^[1][2]

Atherosclerosis (also called arteriosclerosis) occurs when arteries become narrow due to fat buildup called plaque. Normally, arteries deliver blood throughout the body, but when they are narrowed, blood flow is reduced, which can lead to tissue damage and ulcer formation.^[1]

Prolonged pressure on the skin, especially over bony areas, can cause tissue damage and breakdown. This happens when blood flow is restricted to the area for extended periods.^[2][4]

Physical trauma such as cuts, burns, or injuries can damage skin integrity and lead to ulceration, especially when wounds fail to heal properly or become infected.^[4]

Several factors can increase your risk of developing skin ulcers:^[1][4][5]

• Being immobile or bedridden
• Advanced age
• Obesity
• Smoking
• Lack of physical activity
• Deep vein thrombosis (blood clots in leg veins)
• Chronic health conditions such as peripheral artery disease, venous insufficiency, or autoimmune disorders
• Long hours of standing

Different types of skin ulcers

Venous skin ulcers

Venous skin ulcers (also called stasis leg ulcers) are shallow, open sores that develop in the skin of the lower leg due to poor blood circulation. They occur when damage to the valves inside leg veins prevents blood from returning properly to the heart. Instead, blood collects in the lower legs, causing them to swell. This swelling puts pressure on the skin, which can cause ulcers.^[2]

These ulcers usually form on the sides of the lower leg, above the ankle and below the calf. The first sign is often skin that turns dark red or purple, which may also become thick, dry, and itchy. Venous skin ulcers are slow to heal and tend to come back if preventive steps are not taken.^[5][7]

Arterial (ischemic) skin ulcers

Arterial ulcers develop when the arteries fail to deliver enough oxygen-rich blood to the lower limbs. Without a steady supply of oxygen, the tissues die and an ulcer forms. These ulcers can appear on the outside of the ankle, feet, and toes. They are less common than venous skin ulcers but tend to be extremely painful.^[2][7]

Neuropathic skin ulcers

Neuropathic skin ulcers (also known as diabetic neuropathic ulcers) are a common complication of uncontrolled diabetes. Over time, elevated blood sugar levels cause nerve damage, resulting in reduced or total loss of feeling in the hands and feet. This condition, called neuropathy, occurs in approximately 60 to 70 percent of people with diabetes.^[2]

These ulcers develop from smaller wounds such as blisters or small cuts. A person with diabetes-associated neuropathy might not realize they have an ulcer until it starts leaking fluid or becomes infected, at which point they may notice a distinct odor.^[2]

Pressure ulcers (bedsores)

Decubitus ulcers, also called pressure sores or bedsores, occur as a result of constant pressure or friction on the skin. Skin tissues can withstand a maximum pressure of 30 to 32 millimeters of mercury. Any increase in pressure beyond this range can lead to poor circulation, tissue death, and eventually ulcer formation.^[2]

These ulcers commonly develop on the buttocks, elbows, hips, heels, ankles, shoulders, back, and back of the head. People who are bedridden, wheelchair-bound, or immobile for extended periods are at higher risk. If left untreated, pressure ulcers can cause damage to tendons, ligaments, and muscle tissue.^[2][3]

Buruli ulcer

Buruli ulcer is a medical condition caused by the Mycobacterium ulcerans bacteria. An infection with this bacteria can form large ulcers on the arms and legs. If left untreated, Buruli ulcer can result in permanent physical damage and disability.^[2]

How doctors identify skin ulcers

Your healthcare professional will likely diagnose a skin ulcer by asking questions about your health and looking closely at your legs and the affected area. They will assign a stage to the wound, which helps determine the best treatment approach.^[12]

Your doctor may use duplex Doppler ultrasound to find out what is causing the ulcer. This test shows how well blood is moving through the lower leg.^[7]

Blood tests may be needed to learn about your general health and to check for conditions that might be contributing to the ulcer.^[12]

Your healthcare professional might ask questions such as:^[12]

• When did the ulcer first appear?
• How painful is it?
• Have you had ulcers before?
• What medical conditions have you been diagnosed with?
• What is your routine for changing positions?
• What do you usually eat and drink?

Treatment approaches

With appropriate treatment, many skin ulcers can heal within 6 months. Treatment should always be carried out by a healthcare professional trained in wound care, usually a practice or district nurse.^[10]

Cleaning and dressing the ulcer

The first step is to remove any debris or dead tissue from the ulcer, wash and dry it, and apply an appropriate dressing. This provides the best conditions for healing. A simple non-sticky dressing is typically used and usually needs to be changed 1 to 3 times a week.^[10]

Many people find they can manage cleaning and dressing their own ulcer under the supervision of a nurse.^[10]

Compression therapy

Compression therapy is the main treatment for venous skin ulcers. To improve vein circulation in your legs and treat swelling, your nurse will apply a firm compression bandage over the affected leg. These bandages are designed to squeeze your legs and encourage blood to flow upward towards your heart.^[10]

There are many different types of bandages or elastic stockings used to treat venous leg ulcers, which may be made in 2, 3, or 4 different layers. The application of a compression bandage is a skilled procedure and should only be done by trained healthcare staff. The bandage is usually changed 1 to 3 times a week when the dressing is changed.^[10]

It’s important to wear your compression bandage exactly as instructed. When compression bandages are first applied, they may be painful, but the pain will lessen once the ulcer starts to heal.^[10]

Medications

If your ulcer becomes infected, your doctor may prescribe antibiotics. It’s crucial to take the full course of antibiotics as directed, even if you feel better before finishing them.^[16] Antibiotics are medicines that fight bacterial infections.

Pain medication may be prescribed to help manage discomfort, especially when compression bandages are first applied.^[10]

Advanced treatments

If your ulcer doesn’t heal within a few months, your doctor may recommend other treatments such as:^[7]

• Medicine to speed healing
• Skin grafting for deep or hard-to-heal ulcers
• Vein surgery to prevent ulcers from returning

Possible complications

Infected skin ulcers are serious because the infection can spread throughout the body. If the wound becomes infected, you may notice an odor, pus draining from the wound, increased tenderness, and redness around the area.^[1][5]

In people with diabetes, foot ulcers are particularly concerning. More than half of diabetic foot ulcers are infected at the time of presentation to a clinician, and amputation occurs in 20% of diabetic foot ulcers.^[11]

If left untreated, pressure ulcers can cause damage to tendons, ligaments, and muscle tissue. In severe cases, deeper tissue loss and bone destruction may occur, potentially leading to joint infections.^[2][3]

Prevention and self-care

Call your doctor when you first notice the signs of a skin ulcer, because you may be able to prevent the ulcer from forming. If an ulcer has formed, get treatment right away, as new and smaller ulcers tend to heal faster than larger ones.^[7]

To help prevent skin ulcers and support healing, follow these steps:^[10][16]

• Lift your legs above the level of your heart as often as possible. For example, lie down and prop up your legs with pillows.
• Wear compression stockings or bandages as recommended. They help prevent blood from pooling in your legs. After your ulcer has healed, continue to wear compression stockings, taking them off only when you bathe and sleep.
• Walk daily. Walking helps your blood circulation.
• Change positions often. If you are in a wheelchair, try to change your position every 15 minutes. If you are in bed, move or be moved about every 2 hours.
• Avoid scratching your legs if they feel itchy, as this damages the skin and may lead to further ulcers.
• Be careful not to injure your affected leg, and wear comfortable, well-fitting footwear.
• If you’re overweight, try to reduce your weight with a healthy diet and regular exercise.
• Stop smoking and moderate your alcohol consumption, as these can help ulcers heal faster.
• Eat a diet high in protein and adequate in calories. Good protein sources include fish, chicken, and soy products.

You should call your doctor or seek immediate medical care if:^[16]

• You have signs of infection such as increased pain, swelling, warmth, redness, red streaks leading from the ulcer, pus draining from the ulcer, or fever
• Your ulcer is not healing
• You have new ulcers
• The ulcer starts to bleed and blood soaks through the bandage
• You have new bleeding
• You experience numbness or tingling in your feet or toes
• Your toes become swollen or look pale or blue