Arterial ulcer

What is an arterial ulcer?

An arterial ulcer is a wound on the foot or lower leg caused by a problem with the blood supply to the leg¹. Narrowed or blocked leg arteries leave the skin starved of oxygen and nutrients². It's part of peripheral arterial disease (PAD)¹. Ulcers from artery disease or diabetes most often occur on the foot rather than the leg³. A painful foot or ankle wound that is slow to heal may be a circulation problem, not just a skin problem.

What causes an arterial ulcer, and who gets one?

An arterial ulcer arises when fatty deposits (atherosclerosis) collect inside the leg arteries, narrowing them and limiting the blood that reaches the leg¹. Smoking and diabetes are the main risk factors for PAD⁴. High blood pressure, rheumatoid arthritis and heart disease are also linked to narrowed arteries⁵. Roughly half of people who have both diabetes and a foot ulcer also have PAD, so a foot wound in someone with diabetes warrants closer attention⁶.

What does an arterial ulcer feel like, and how is it diagnosed?

An arterial ulcer is often painful, usually on a toe, heel, bony area, side of the foot or lower leg, with little or no discharge⁵⁷. The foot may feel cold and look pale or bluish and shiny⁵. Pain is often worse at night and eases when the leg hangs down⁵.

Diagnosis uses circulation tests such as the ankle-brachial index (ABI), not feeling for pulses⁸. With diabetes, a normal ABI doesn't rule out PAD, so toe pressure tests may be added⁸⁹. Symptoms suggesting PAD call for an ABI⁹. A wound not healing after 2 weeks is another reason to suspect poor blood supply¹⁰.

What helps an arterial ulcer heal?

A suspected arterial ulcer needs assessment and care from a healthcare professional and referral to a vascular team¹²⁷¹¹. A suspected arterial ulcer points to poor blood supply to the leg¹².

The main treatment is restoring blood flow (revascularisation)¹⁹¹². That may be balloon angioplasty to open a narrowed or blocked artery, or bypass surgery when the blockage is too large for a balloon¹. It's the cornerstone of preventing limb loss when blood supply is severely reduced¹². Which approach suits whom isn't clear yet, so decisions need an experienced vascular team¹²¹³.

Medicines prescribed by a doctor, such as cholesterol, blood-thinning and blood pressure treatments, help manage cardiovascular risk factors in PAD¹¹²¹³. On their own they do little for the limb when blood flow can't be restored¹².

Don't use compression bandages unless a healthcare professional has confirmed that compression is safe²¹⁴¹⁵. Arterial and venous ulcers are treated differently, and compression isn't safe when the blood supply is reduced²¹⁴¹⁵.

A repeat vascular review, rather than only changing dressings, is worth discussing with the team. Talk with the team about your goals, pain and quality of life.

What is the outlook, and how can I stop it coming back?

Outlook depends largely on the circulation. Arterial ulcers are often a sign of advanced PAD, which is linked with a higher risk of serious illness¹⁶. If you have diabetes, PAD makes a foot ulcer more likely to fail to heal or lead to a major amputation¹⁷.

Stopping smoking is the single most important change you can make¹. Exercise also eases PAD symptoms¹; structured exercise, supervised or community-based, is a core part of PAD care⁹, such as a structured or home-based walking program. Agree it with your treating team. Practical help to stop smoking, such as referral to a quit-smoking service, is offered.

If you have diabetes, include foot care and podiatry in your self-care plan¹¹. Even after the wound heals, the artery disease remains, so keep having your circulation checked.

What can make it serious?

• Your foot ulcer is being treated but isn't getting better (ask about a review by the foot team).
• You have diabetes or poor circulation and signs of infection in your foot, toe or nail, such as redness, warmth, swelling, pus, a bad smell or more pain.
• You have diabetes, poor circulation or reduced feeling in your feet and notice a new wound, sore, blister or colour change on your foot, or a sore that isn't healing.
• You have constant pain in your foot or toes that is worse at night or when your legs are raised, and eases when you hang your leg down (this can be a sign of poor circulation).
• The skin on your toes or foot turns dark or black, or a wound turns black and smells bad.
• You have a foot wound, ulcer or infection and also feel very unwell, with confusion or slurred speech, severe shivering or muscle pain, severe breathlessness, mottled or discoloured skin, or little or no urine (possible sepsis).
• Your leg or foot suddenly turns cold and pale, with pain or numbness, or you suddenly can't move it.