Venous ulcer is defined by the American Venous Forum as "a full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by chronic venous disease, based on venous duplex ultrasound testing." Venous ulcers are wounds that are thought to occur due to improper functioning of venous valves, usually of the legs (hence leg ulcers). They are an important cause of chronic wounds, affecting 1% of the population. Venous ulcers develop mostly along the medial distal leg, and can be painful with negative effects on quality of life. Exercise, together with compression stockings, increases healing. The NICE guideline recommends that everyone with a venous leg ulcer, even if healed, should be referred to a vascular specialist for venous duplex ultrasound and assessment for endovenous surgery. Signs and symptoms Signs and symptoms of venous ulcers include: Moderate pain, which improves on elevation (unlike arterial ulcers which worsen with elevation) Irregular, sloping edges Associated oedema, due to increased hydrostatic pressure, which contributes to 'atrophie blanche' 'Atrophie blanche', localised loss of skin pigmentation due to death of erythrocytes and scarring Lipodermatosclerosis, a hardening of the skin which can lead to an "inverted champagne bottle" appearance to the leg Associated superficial varicose veins or "ankle flare", a collection of small, dark, engorged superficial veins Pathophysiology The exact cause of venous ulcers is not certain, but a common denominator is generally venous stasis, which may be caused by chronic venous insufficiency, and/or congestive heart failure. Venous stasis causes the pressure in veins to increase. The body needs the pressure gradient between arteries and veins in order for the heart to pump blood forward through arteries and into veins. When venous hypertension exists, arteries no longer have significantly higher pressure than veins, and blood is not pumped as effectively into or out of the area. Venous hypertension may also stretch veins and allow blood proteins to leak into the extravascular space, isolating extracellular matrix (ECM) molecules and growth factors, preventing them from helping to heal the wound. Leakage of fibrinogen from veins as well as deficiencies in fibrinolysis may also cause fibrin to build up around the vessels, preventing oxygen and nutrients from reaching cells. Venous insufficiency may also cause white blood cells (leukocytes) to accumulate in small blood vessels, releasing inflammatory factors and reactive oxygen species (ROS, free radicals) and further contributing to chronic wound formation. Buildup of