Deborah A Simon, research nurse specialist1, Francis P Dix, research fellow1, Charles N McCollum, professor of surgery1
1 Academic Department of Surgery, Wythenshawe Hospital, Manchester M23 9LT
Correspondence to: C N McCollum cnmcc@man.ac.uk

Introduction
Sources and search criteriaCauses of venous ulcerationDiagnosis and investigationManagement of the ulcerFuture researchReferences
Leg ulcers are a big problem for both patients and health service resources.
Most ulcers are associated with venous disease, but other causes or contributing factors include immobility, obesity, trauma, arterial disease, vasculitis, diabetes, and neoplasia (box 1). In the United Kingdom, venous leg ulceration alone has been estimated to cost the NHS £400m ($720m; 600m) a year.1-3 Much of this cost is accounted for by community nursing services; district nurses spend up to half of their time caring for patients with ulcers.
Most venous leg ulcers could be healed if patients were admitted to hospital for continuous leg elevation. Shortage of hospital beds, the high cost of inpatient care, and the need to maintain independence in this elderly population of patients mean that this once popular approach is now rarely practical.
Furthermore, ulcers often recur when the patient returns home and resumes a lifestyle in which most of the day is spent with the legs in dependency.
Outpatient systems of care that maintain mobility and avoid the complications of bed rest are more cost effective and appropriate. Outpatient and community based care also maintain independence and quality of life.
Care for patients with leg ulcers has improved in the past two decades as research based approaches have been adopted. Community leg ulcer clinics using compression bandaging have dramatically improved healing rates and reduced costs, but close supervision by leg ulcer nurse specialists is essential if standards are to be maintained.We have reviewed the evidence for this approach and on new treatments that may improve care of leg ulcers in the future.