5.1 Venous / LEVD Ulcer Assessment
Key Takeaways
- LEVD ulcers cluster in the gaiter, especially near the medial malleolus: irregular edges, ruddy granulation, and moderate-to-heavy exudate on a swollen, stained limb.
- Look for hemosiderin, varicose veins, stasis dermatitis, atrophie blanche, and lipodermatosclerosis with an inverted champagne-bottle contour.
- Aching and heaviness that ease with elevation support venous hypertension; arterial rest pain typically worsens when the leg is raised.
- CEAP C5 means a healed venous ulcer; C6 means an active ulcer—do not treat those two categories as interchangeable.
- Pulses are often present in LEVD, but ABI is still required before sustained high compression; stasis dermatitis is not the same disease as cellulitis.
5.1 Venous / LEVD Ulcer Assessment
Quick Answer: Lower-extremity venous disease (LEVD) ulcers usually sit in the gaiter region, especially near the medial malleolus. Edges are irregular, the bed is often ruddy and moist, and drainage is moderate to heavy. The same limb shows edema, hemosiderin, and sometimes lipodermatosclerosis. Pulses are frequently present, yet you still obtain an ABI before high compression. CEAP C5 is a healed venous ulcer; C6 is an active one. Stasis dermatitis itches and scales on chronic stain; cellulitis is tender, spreading, and often systemic.
Independent OpenExamPrep teaching for this chapter is pattern recognition at the bedside. These materials help learners study CWCN assessment topics; they are not an official WOCNCB product and do not claim sponsor approval. Outline items 010302 (knowledge of wound etiology beyond pressure injury) and 010311 (skill in lower-extremity assessment) show up as case stems: Can you tell a wet medial gaiter wound from a pale toe ulcer, and do you still check perfusion before you wrap?
Where LEVD ulcers live and what they look like
Chronic venous hypertension comes from reflux, obstruction, or both. High ambulatory venous pressure in dermal capillaries leaks red cells and protein. Iron remains as hemosiderin; inflammation and fibrosis follow. The distal third of the leg—the gaiter, from below the tibial tubercle to above the malleoli—takes the load. The medial malleolus is the classic site because of posterior tibial perforators, but lateral gaiter ulcers still occur and circumferential disease can belt the whole ankle.
Typical morphology:
- Location: gaiter, especially medial; not the plantar metatarsal heads and not a dry toe tip.
- Shape: irregular, often shallow; not a neat circle parked on a single bony prominence.
- Base: ruddy, moist granulation; yellow fibrin is common; dry black eschar is not the usual venous picture.
- Exudate: moderate to heavy, serous or serosanguineous; unmanaged fluid macerates the periwound.
- Pain: aching, heaviness, tightness that improves with elevation and often worsens after prolonged standing or sitting with the legs down.
- Edges: sloping or serpiginous, not punched-out and pale.
A person can have varicose veins and a separate arterial or pressure wound. Do not force a venous label onto a necrotic hallux because the calf also has varicosities.
History that supports LEVD includes prior deep-vein thrombosis, pregnancy-related varicose veins, obesity, standing occupations, prior vein surgery, and previous ulcers in the same gaiter. Ask what happens overnight: a limb that is smaller in the morning after elevation is a venous clue. Ask about compression they already tried—and whether they removed it because of pain, which may be arterial rather than “nonadherence.”
Skin changes that travel with the ulcer
Document the limb, not only the hole.
Edema is pitting early and may firm as protein-rich fluid organizes. Compare both calves with the patient standing and supine. Isolated pretibial swelling that vanishes with elevation differs from swelling that includes the dorsum of the foot and toes; the latter should make you think of a lymphatic contribution (phlebolymphedema in section 5.4).
Hemosiderin is rust-brown, gray-brown, or darker dermal staining. It does not blanch. It is not a culture plate. In richly pigmented skin, compare with the contralateral gaiter and feel for induration rather than waiting for a textbook rust color.
Lipodermatosclerosis (LDS) is chronic fibrosing panniculitis of the distal leg. Skin feels woody and bound down. The contour tapers from a swollen proximal calf to a narrow ankle—the inverted champagne-bottle (bowling-pin) shape. Acute LDS can be red, warm, and painful and is repeatedly labeled cellulitis; it often recurs in a stocking distribution without fever or lymphangitic streaking.
Atrophie blanche is ivory-white, atrophic, scar-like plaques with telangiectatic dots, often around the ankle. It marks severe cutaneous venous hypertension and a tendency toward painful, slow-healing ulcers—not a cosmetic afterthought.
Varicose veins, an ankle flare of small veins (corona phlebectatica), and stasis dermatitis (gaiter eczema: scale, itch, erythema or violaceous change, sometimes weeping) complete the picture. Scratching and topical antibiotics add contact dermatitis on top of venous eczema.
| Finding | LEVD / venous pattern | Why it matters on a CWCN item |
|---|---|---|
| Location | Gaiter, medial malleolus common | Separates venous disease from plantar neuropathic and distal arterial ulcers |
| Edges and bed | Irregular; ruddy granulation | Punched-out pale beds suggest arterial disease |
| Exudate | Moderate to heavy | Drives absorbency and maceration risk |
| Edema plus hemosiderin | Typical | Chronic stain is not an antibiotic target by itself |
| LDS / inverted bottle | Advanced skin change | Woody tightness is not untreated cellulitis by default |
| Pain with elevation | Often improved | Arterial rest pain typically worsens with elevation |
| Pulses | Often present | Presence does not skip ABI before compression |
CEAP as a shared language, not a trivia contest
CEAP classifies chronic venous disorders: Clinical, Etiologic, Anatomic, Pathophysiologic. Wound nurses live mainly in the C (clinical) column. You do not need every C0–C6 string memorized as a party trick, but you must not confuse a healed ulcer with an open one.
Clinical categories you will see on duplex reports and in clinic notes:
- C0: no visible or palpable signs of venous disease
- C1: telangiectasias or reticular veins
- C2: varicose veins
- C3: edema without skin change in that scheme
- C4: skin changes (pigmentation, eczema, LDS, atrophie blanche)
- C5: healed venous ulcer (a scar in a venous limb)
- C6: active venous ulcer
High-yield: C5 is closed; C6 is open. A stained gaiter with a white scar and no current hole is C5, not “almost C6.” Varicose veins alone are not ulcer-class disease. The E, A, and P letters (primary versus secondary, superficial versus deep versus perforator, reflux versus obstruction) belong on the vascular report. You use them to understand why ablation or stenting is being discussed; you do not recite a 12-character code on every dressing note.
Pulses, ABI, and the compression gate
Venous limbs often have palpable dorsalis pedis and posterior tibial pulses. That is expected. It is not permission to skip perfusion testing when you plan sustained compression. Mixed arterial disease hides under a ruddy, wet ulcer. Chapter 3 already taught ABI bands; here you apply them. If the morphology is venous but the ABI is 0.55, you do not roll a 30–40 mmHg multilayer wrap because the wound “looks venous.” If ABI sits in the typical normal band, pulses agree, and the picture is gaiter-venous, high compression is on the table. Wrap construction lives in the compression chapter; this section’s rule is do not compress an ischemic limb you failed to screen.
Inspect both legs, shoes, and the pattern of sock marks. Palpate pulses, listen with Doppler if a pulse is missing, and document capillary refill and temperature as supporting clues, not as stand-alone clearance for a four-layer bandage.
Stasis dermatitis versus cellulitis
This differential is a classic trap.
Stasis dermatitis is often bilateral or worse on the chronically venous side, itchy more than exquisitely tender, scaly or crusted, and sits on hemosiderin. The patient is commonly afebrile. The border is indistinct. Allergic contact dermatitis from neomycin, lanolin, or adhesives can flare the same territory.
Cellulitis is typically unilateral, spreading, tender, warmer than the opposite limb, and may include fever, chills, leukocytosis, lymphangitic streaking, or a new portal of entry. It evolves over hours to a few days, not over years of brown stain.
Do not culture rust-brown pigment. Do not give weeks of intravenous antibiotics for chronic bilateral gaiter eczema. Do treat true cellulitis promptly. Acute lipodermatosclerosis can mimic both; look for woody tightness in a stocking distribution, recurrence in the same place, and lack of systemic toxicity.
Scenario: the “infected stain”
A 64-year-old cashier has a 3.2 × 2.4 cm irregular ulcer just above the left medial malleolus, a ruddy bed, moderate serous drainage, pitting edema to mid-calf, and rust-brown non-tender staining of both gaiters. The ache eases when she puts her feet up at night. Dorsalis pedis and posterior tibial pulses are 2+. The emergency department diagnosed “bilateral cellulitis” because both legs are dark. She is afebrile, the white count is normal, and the darkness has been present for years. The CWCN names LEVD with an active (C6) ulcer and chronic hemosiderin, obtains an ABI before compression, treats stasis dermatitis as eczema rather than streptococcal disease, and documents that bilateral chronic stain is not an indication for bilateral IV antibiotics. If one limb suddenly becomes hotter, more painful, and erythema marches up the shin with fever, that is a different visit—and a different diagnosis.
Keep the sequence: location and morphology first, limb skin next, symptoms with elevation, pulses plus ABI before compression, and infection only when the inflammatory story is acute and asymmetric.
Which combination best supports an LEVD (venous) ulcer rather than an arterial or plantar neuropathic ulcer?
A distal calf feels woody, and the ankle is narrow compared with a swollen proximal calf. Which finding are you documenting?
In CEAP clinical language, what is the difference between C5 and C6 disease?
Both gaiters have years of non-tender brown staining and scale. The patient is afebrile. One new irregular medial ulcer weeps serous fluid. Which interpretation is most accurate?