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🦵 Venous Ulcers – PLAB 2 Focused Guide

Updated: Jul 21

Venous leg ulcers are the most common type of leg ulcer, and you’re likely to see them in PLAB 2 scenarios involving chronic leg wounds, wound care stations, or patient counselling. This blog gives you the key clinical knowledge, patient communication points, and OSCE tips to help you ace the station.


🔍 What Are Venous Ulcers?

Venous ulcers occur due to chronic venous insufficiency, where blood pools in the lower legs because of faulty vein valves. This leads to venous hypertension, skin damage, and eventually ulcer formation.


Lay Explanation Sample:

"You have a venous ulcer, which means blood isn’t flowing properly in your leg veins. Even with the right stockings, it hasn’t healed, which may mean deeper vein problems. There are treatments we can add, like tablets to improve circulation or procedures to close off damaged veins.”

🧠 Pathophysiology (Keep It OSCE-Simple)

  • Valve failure (due to DVT, varicose veins, obesity, prolonged standing)→ Blood pools in lower leg veins→ High pressure → fluid leaks into tissue→ Inflammation, skin breakdown → venous ulcer


📋 Clinical Features

Feature

Description

Location

Lower leg, especially medial gaiter area

Ulcer

Shallow, irregular, red base, often exudative

Surrounding skin

Hyperpigmentation, lipodermatosclerosis, venous eczema

Symptoms

Aching, swelling worse at end of day, relieved by elevation

🔬 Diagnosis


🧑‍⚕️ Clinical Exam:

  • Pulses present (rule out arterial disease)

  • Look for signs of chronic venous disease


🧪 Investigations:

  • ABPI (Ankle-Brachial Pressure Index):

    • 0.8 → safe for compression

    • <0.8 → avoid/modify compression; investigate arterial disease

  • Duplex ultrasound: assess for reflux or obstruction

  • Swabs only if infected; no routine use


💊 Treatment Overview


✅ Mainstay: Compression Therapy

  • Multilayer bandaging or compression stockings (Class 2 or 3)

  • Only if ABPI ≥ 0.8

  • Reduces venous pressure and promotes healing


❗ If patient refuses stockings:

  • Explore reasons (e.g. tightness, itchiness, pain)

  • Offer alternatives:

    • Velcro wraps

    • Lighter compression

    • Custom-fitted stockings

  • Use emollients for itching

  • Stocking aids & morning application can help


💡 Adjunctive Treatments


Pentoxifylline 400 mg TDS

  • Mechanism of Action:

    • Hemorrheologic agent: Pentoxifylline improves the flow properties of blood, making it less viscous and more easily able to pass through narrowed or partially obstructed vessels.

    • Reduces blood viscosity: By increasing the flexibility of red blood cells and decreasing platelet aggregation, it enhances blood flow, especially in the microcirculation.

    • Improves oxygen delivery: Better blood flow means more oxygen and nutrients can reach ischemic tissues, supporting wound healing.

    • Anti-inflammatory effects: It inhibits TNF-α and other pro-inflammatory cytokines, which may help reduce chronic inflammation around the ulcer.

  • Clinical Use:

    • Adjunct to compression therapy for venous leg ulcers, as per NICE guidelines.

    • Can be beneficial even in patients with mild to moderate arterial disease (ABPI between 0.5–0.8), although caution is advised, and specialist supervision is ideal.

  • Evidence:

    • Multiple trials and meta-analyses have shown faster ulcer healing rates when pentoxifylline is used alongside compression therapy compared to compression alone.

  • Precautions:

    • Use cautiously in patients with severe cardiac arrhythmias, recent cerebral or retinal hemorrhage, or bleeding disorders.

    • Monitor for side effects like nausea, dizziness, or hypotension.


🛡️ Supportive Measures

  • Leg elevation when sitting

  • Regular walking to activate calf pump

  • Weight loss if overweight

  • Avoid trauma to affected leg

  • Emollients to prevent dry skin and eczema


💉 Surgical Options (NHS Covered if Indicated)

If ulcers fail to heal after 2–3 months of compression:

  • Refer to vascular surgery for:

    • Endovenous laser ablation (EVLA)

    • Foam sclerotherapy

    • Radiofrequency ablation (RFA)

These correct venous reflux and reduce recurrence risk.Covered by the NHS when medically indicated (not cosmetic).


🚩 When to Refer Urgently

  • ABPI < 0.5 or suspected critical limb ischaemia

  • Spreading infection or suspected sepsis

  • Rapidly worsening ulcer

  • Suspicion of malignancy (e.g. Marjolin ulcer)



📌 Key PLAB 2 Takeaways

  • Always check ABPI before applying compression

  • Compression is lifelong even after ulcer heals

  • Pentoxifylline is a valid adjunct

  • Address lifestyle factors (obesity, immobility, smoking)

  • NHS covers surgical treatment if conservative therapy fails


📚 References:

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