Prevention of trophic ulcers: how to reduce the risk of occurrence and recurrence

Prevention of trophic ulcers begins not with ointments or wound dressings, but with managing the underlying condition that can lead to skin damage. In venous insufficiency, the primary focus is on reducing venous congestion and edema, compression therapy as indicated, physical activity, and treatment of pathological venous reflux. In diabetes, prevention revolves around regular foot examinations, appropriate footwear, early removal of calluses and other pre-ulcer lesions, and assessment of neuropathy and arterial blood flow. In arterial disease, preventative foot care and treatment of the underlying peripheral arterial disease are particularly important.

If an ulcer has already occurred and has completely healed, prevention becomes even more important. The strongest evidence base exists for preventing recurrent venous ulcers: long-term compression therapy reduces the likelihood of recurrence, and if superficial venous insufficiency is detected, treatment of pathological reflux further reduces this risk. [1]

The term "trophic ulcer" itself does not denote a single disease. Leg ulcers can be venous, arterial, diabetic, pressure-related, trauma-related, inflammatory, and other causes. Therefore, there is no single preventative measure for everyone. [2]

What exactly do you need to protect yourself from?

A skin injury becomes a chronic ulcer when conditions exist that interfere with normal tissue repair: long-term venous edema, poor arterial blood supply, loss of sensation due to neuropathy, repeated pressure on one area of the foot, chronic inflammation, or a combination of several factors.

Therefore, effective prevention should primarily target these mechanisms.

Situation	The main problem	What is most important for prevention?
Chronic venous insufficiency	Venous hypertension and edema	Compression as indicated, movement, edema control, treatment of venous reflux
Healed venous ulcer	High risk of re-injury	Long-term compression and evaluation of the possibility of treating insufficient veins
Diabetes with neuropathy	Loss of sensation and repeated mechanical stress	Examination of feet, footwear, elimination of pre-ulcer changes, regular monitoring
Peripheral arterial disease	Insufficient blood supply to tissues	Vascular treatment, preventative foot care, risk factor management
Mixed arterial-venous disease	Simultaneous congestion and ischemia	Individually selected compression only after vascular assessment
Severe edema and lymphatic component	Constant tension of the skin and disruption of its barrier function	Controlling swelling and treating its cause

This distinction is fundamental: for example, a compression stocking can be one of the main preventative measures after a venous ulcer, but independent use of strong compression in the case of severe arterial insufficiency can be unsafe. [3]

Prevention of venous trophic ulcers

In chronic venous disease, the goal of prevention is to reduce venous hypertension, swelling, and inflammatory changes in the skin before a new wound occurs.

The European Society for Vascular Surgery recommends compression stockings of at least 15 mmHg for symptomatic chronic venous disease. For severe edema class C3 according to the CEAP classification, compression stockings with a pressure of approximately 20-40 mmHg at the ankle are recommended, and for lipodermatosclerosis or white atrophy of the skin class C4b, this range is also used to reduce tissue compaction. [4]

However, there's an important caveat here. Compression is well-established for reducing symptoms and swelling in chronic venous disease, and the strongest evidence for ulcer prevention specifically relates to preventing the recurrence of healed venous ulcers. Therefore, the statement "compression stockings are guaranteed to prevent the first venous ulcer in anyone with varicose veins" would be too categorical. [5]

Compression after ulcer healing

After complete healing of a venous ulcer, long-term compression therapy is one of the main preventive measures. The ESVS recommends considering it to reduce the risk of ulcer recurrence, and the 2024 German guidelines specifically recommend medical compression hosiery after venous ulcer healing. [6]

A recent Cochrane review included eight studies and 1,995 people with healed venous ulcers. Higher levels of compression may have been more effective in preventing recurrence than no compression or lower levels of compression, although some of the evidence was of low certainty. In one study, European Class 3 compression was associated with approximately 210 recurrences per 1,000 people versus 457 per 1,000 without compression. [7]

But "stronger" doesn't always mean "better" for a particular patient. As compression pressure increases, some people find it more difficult to wear stockings regularly. Cochrane notes that patients may be more likely to adhere to lower compression, and the ESVS also emphasizes the importance of adherence. Therefore, the best option is generally adequate, safe compression that a person can actually use consistently, rather than the strongest stocking that remains in the closet. [8]

Treatment of venous reflux prevents recurrence of ulcers

If superficial venous insufficiency is detected by duplex ultrasound after an ulcer, prophylaxis should not automatically be limited to lifelong wearing of a stocking.

The ESVS recommends treatment of insufficient superficial veins in patients with healed venous ulcers to reduce the risk of recurrence; this recommendation has a class I and level of evidence of A. The German 2024 guidelines come to a similar conclusion. [9]

This is also supported by clinical studies. Long-term data from studies of surgical and endovenous treatments show that eliminating superficial venous reflux in addition to compression can make the result more durable and reduce the incidence of recurrent ulcers. [10]

In practice, this means that a person who has already had a venous ulcer should discuss with a vascular surgeon or phlebologist not only the stockings, but also whether the cause of the venous hypertension has not yet been eliminated.

Movement and function of the calf muscle pump

Walking and ankle movement help the calf muscles act as a pump, pushing venous blood upward. Therefore, prolonged immobility, limited ankle motion, and weak calf muscles can impair venous outflow.

The ESVS recommends exercise for symptomatic chronic venous disease. The guidelines discuss walking, leg muscle strength, and ankle mobility; these may improve muscle pump function and reduce venous symptoms. [11]

The 2024 German guidelines recommend continuing physical activity even after a venous ulcer has healed to prevent recurrence. Regular walking and foot and ankle exercises are considered practical options. [12]

Constant walking or intense exercise isn't necessary. The more important goal is to avoid prolonged periods of inactivity. If you have to sit for long periods, it's helpful to periodically move your feet, flex and extend your ankles, and stand for short walks if physically possible.

Do I need to elevate my legs?

In venous oedema, elevating the legs during rest may reduce dependent fluid accumulation. The NHS includes periodic leg elevation, along with physical activity and compression, in its preventive recommendations for people at risk of venous ulcers. [13]

This is an additional measure, not a complete replacement for compression or treatment of venous reflux. A person remains in an upright position throughout the day, so the habit of elevating the legs several times a day alone will not eliminate chronic venous hypertension.

Weight control

Chronic venous disease is more severe in obesity, and severe edema and limited mobility can exacerbate each other. European guidelines consider weight loss in obesity as part of a conservative strategy for chronic venous disease. [14]

In the 2024 German guidelines, normalization of body weight is separately recommended for obese people after healing of a venous ulcer to prevent recurrence. [15]

However, weight loss should not be considered a standalone "treatment for venous ulcers." It can improve overall venous load, mobility, and swelling control, but it does not replace venous examinations and other preventative measures.

Foot skin care

Prevention involves maintaining the integrity of the skin. Dryness, itching, venous eczema, scratching, and cracking create additional sites of skin damage, especially when combined with swelling and already impaired microcirculation.

German guidelines recommend individualized skin care with hypoallergenic products. Moisturizing ingredients, including urea or glycerin, can be used for dry and itchy skin, and regular care helps maintain the skin's elasticity and barrier function. [16]

If the skin is severely itchy, avoid constant scratching of the shin: mechanical damage can become a gateway for infection and a potential site for wound formation. Venous eczema may require separate treatment, and if an allergy to creams, adhesives, or dressing components is suspected, an assessment for contact dermatitis is necessary. [17]

Prevention of ulcers in diabetes mellitus

With diabetes, prevention is different. The main risks are loss of protective sensation, arterial insufficiency, foot deformities, and repetitive pressure that a person sometimes doesn't even feel.

The current recommendation of the International Working Group on Diabetic Foot (IWGDF 2023) recommends annual examinations, even for people with diabetes at the lowest risk, with an assessment of peripheral neuropathy and peripheral arterial disease. If loss of protective sensation or arterial disease is detected, examinations become more frequent and include foot deformities, calluses, pre-ulcer lesions, and a history of ulcers and amputations. [18]

For higher risk, the recommended intervals vary by category: approximately every 6–12 months for IWGDF risk 1, every 3–6 months for risk 2, and every 1–3 months for the highest risk category 3. [19]

Daily foot examination

People with diabetes and an increased risk of ulcers should regularly inspect their feet, including the soles and areas between the toes. Any blister, crack, bleeding under a callus, abrasion, redness, a new callus, or a small wound require special attention.

The IWGDF recommends daily examination of the feet and prompt contact with a specialist trained in diabetic foot care if a pre-ulcerative change appears or is suspected.[20]

This approach is especially important in neuropathy: the absence of pain does not mean the absence of damage.

You can't walk barefoot

For a person with diabetes and loss of protective sensation, even a small pebble, a hot floor, or a barely noticeable unevenness can cause injury.

IWGDF recommends that people at risk not walk barefoot, but only in socks without shoes or thin house slippers - both at home and outdoors. [21]

This is a good example of the difference between the average person and someone with neuropathy: the recommendation is determined not by the diabetes diagnosis itself, but by the actual risk of foot damage.

The right shoes

Shoes should fit the shape of your foot and not create areas of excessive pressure. This is especially important for people with deformed toes, prominent bones, previous ulcers, or amputations.

The IWGDF recommends properly fitted adaptive or therapeutic footwear for individuals at moderate to high risk. After a previous plantar ulcer, preference is given to therapeutic footwear, which has been shown to reduce plantar pressure during walking. [22]

Therefore, buying "diabetic shoes" based solely on the label on the box isn't enough. The fit, shape, absence of potentially damaging seams, and the ability of a specific design to reduce stress in vulnerable areas of the foot are all important.

Calluses in diabetes are not just a cosmetic problem.

Excessive callus, blister, crack, and hemorrhage in the skin are considered pre-ulcerative changes by the IWGDF, especially when associated with neuropathy. Their detection should lead to the elimination of the cause of the pressure and professional treatment, rather than aggressive self-removal. [23]

Cutting off a callus with a blade or using aggressive keratolytic agents on a foot with impaired sensitivity can cause damage that a person will not notice until later.

Washing and moisturizing feet for diabetics

The IWGDF recommends washing your feet daily, drying the skin thoroughly, especially between the toes, using moisturizers if dry, and properly caring for your nails. [24]

Moisturizer is usually applied to dry skin on the feet, but avoid creating a constant moist environment between the toes. Fungal infections of the skin or nails require separate evaluation and treatment.

Foot temperature monitoring

For selected patients with a moderate or high risk of recurrent diabetic ulcers, the IWGDF recommends training in home monitoring of foot skin temperature. Localized temperature increases may occur before visible tissue damage and may be used as a signal to temporarily reduce activity and seek advice. [25]

This is not a mandatory procedure for every person with diabetes and is not a replacement for daily screening. The guidelines specifically state it as an option to be considered in appropriate patients.

Prevention of ulcers in leg arterial disease

With peripheral arterial disease, the main problem is insufficient tissue blood supply. Therefore, prevention involves not only protecting the skin but also comprehensive treatment of the vascular disease itself.

The 2024 American College of Cardiology and American Heart Association guidelines consider preventive foot care as an independent component of peripheral arterial disease management. They recommend examining bare feet during well-child visits, performing at least an annual comprehensive foot evaluation, and considering therapeutic footwear in patients at high risk for ulcers or amputation. [26]

High-risk factors include previous ulcer or amputation, neuropathy, foot deformities, calluses, chronic kidney disease, diabetes with poor glycemic control, and continued smoking.[27]

Treatment of peripheral arterial disease also includes correction of cardiovascular risk factors—smoking cessation, treatment of dyslipidemia, hypertension, and diabetes, use of antithrombotic therapy for specific indications, and structured exercise programs. If chronic limb-threatening ischemia develops, revascularization is used to prevent limb loss.[28]

This does not mean that a person should self-administer aspirin, an anticoagulant, or other vascular medication "for ulcer prevention": the medication strategy depends on the confirmed diagnosis and the individual's risk of bleeding and cardiovascular complications.

Why you shouldn't prescribe strong compression on your own

Compression stockings are often associated with the prevention of trophic ulcers, but before significant compression, the arterial blood supply to the leg must be considered.

For example, the ESVS classifies severe arterial disease with an ankle-brachial index below 0.6 and/or ankle pressure below 60 mmHg as severe limitations for long-term compression. The German guidelines use a slightly different threshold for severe peripheral arterial disease - an ankle-brachial index below 0.5, but also specify ankle pressure below 60 mmHg or toe pressure below 30 mmHg. [29]

This is a real-world example of differences between guidelines, not a contradiction in principle: the more severe the ischemia, the more cautious the compression therapy should be. In mixed arterial-venous disease, pressure is selected individually after vascular assessment, sometimes using modified compression under medical supervision. [30]

Therefore, a person with cold feet, a weak pulse, foot pain at rest, known peripheral arterial disease, or diabetes with vascular complications should not buy heavy compression stockings on their own just because their feet are swelling.

What to do if your legs are constantly swollen

Persistent swelling alone does not prove venous insufficiency. Venous, lymphatic, cardiac, renal, drug-related, and other disorders can be the cause.

If chronic venous disease with edema is diagnosed, the ESVS recommends compression therapy to reduce swelling. If a clinically significant lymphedema component is present along with the venous ulcer, the German guidelines recommend complex anti-edema therapy after contraindications have been ruled out. [31]

A preventative mistake is to treat swelling for years only with gels without determining its origin.

Is it possible to prevent ulcers with just cream?

No. Moisturizer can reduce dryness and cracking of the skin, so skin barrier care does have preventative value. However, it does not treat venous hypertension, arterial ischemia, or diabetic neuropathy. [32]

The same applies to various “venotonic” gels, ointments and cosmetics: they cannot be considered a replacement for compression, vascular diagnostics, adequate footwear or treatment of the underlying disease.

Practical prevention: what you can do every day

The general part of prevention is quite simple, but specific measures need to be adapted to the cause of the risk:

1. Inspect the skin of your legs and feet, especially if you have had an ulcer before, diabetes, neuropathy, or arterial disease.
2. Do not ignore small injuries - a crack, a blister, a chafing, a hemorrhage under a callus, a wet area.
3. Maintain the skin in good condition, preventing severe dryness, scratching and cracking.
4. Wear appropriate footwear; if you have diabetic neuropathy, do not go barefoot.
5. Maintain physical activity unless contraindicated and avoid prolonged periods of complete immobility.
6. Monitor swelling if its cause is identified.
7. Use the prescribed compression regularly, not just when your leg is very swollen.
8. Do not smoke, especially if you have peripheral arterial disease.
9. Undergo vascular or diabetic monitoring at a frequency appropriate to risk.
10. If an ulcer has already occurred, do not consider its healing to be the end of treatment for the cause that led to it.

What to check after a venous ulcer heals

Healed skin is the result of wound treatment, but venous pathology often persists.

After epithelialization, it makes sense to make sure that the following are determined:

• cause of ulcer;
• state of arterial blood flow;
• presence of superficial and deep venous reflux or obstruction;
• appropriate class and size of compression hosiery;
• a person's ability to put it on independently;
• severity of residual edema;
• skin condition;
• ankle mobility;
• the need for endovenous treatment.

It is this causal approach that better aligns with modern guidelines than the “wound closed – treatment completed” model. [33]

When to see a doctor before an ulcer appears

The appearance of a small injury on the leg of a high-risk person is already a reason for a more rapid assessment.

In diabetes, it is especially important to show a doctor or diabetic foot specialist any new blister, crack, bleeding under a callus, red area, or wound, especially if sensation is decreased. The IWGDF recommends promptly seeking professional evaluation if a preulcer lesion appears or is suspected. [34]

Signs of arterial disease include a new wound that is not healing well, foot pain at rest, and coldness or discoloration of the foot. Guidelines for Peripheral Arterial Disease emphasize the need for early detection of ulcers and chronic ischemia that threatens the limb. [35]

In venous disease, indications for routine vascular evaluation include progressive persistent edema, marked thickening of the skin, venous eczema, white scar-like areas of skin, a previous ulcer, or recurrent injury in the same area. [36]

When urgent medical care is needed

Urgent evaluation is needed if a wound that has already appeared is accompanied by rapidly spreading redness, severe swelling, fever, rapidly increasing pain, or a general deterioration in condition.

Particularly worrisome are signs of critical circulatory failure: sudden or severe foot pain, a cold, pale, or cyanotic limb, rapidly developing necrosis, or a non-healing wound combined with signs of severe ischemia. Peripheral arterial disease with chronic limb-threatening ischemia requires specialized vascular treatment, including consideration of revascularization. [37]

What is often misunderstood

"Trophic ulcers only occur due to varicose veins." No. Venous insufficiency is one of the main causes, but ulcers also occur with arterial disease, diabetes, and a number of other conditions. [38]

"Once the ulcer has healed, compression stockings are no longer needed." This is often not true for venous ulcers: it is after healing that long-term compression is used to reduce the risk of recurrence. [39]

"The more compression, the better." Higher compression may indeed be better at preventing venous ulcer recurrence, but it must be safe in terms of arterial blood supply and tolerated by the patient.[40]

"If there's no pain with diabetes, the foot is healthy." With neuropathy, a person may lose protective sensation and not feel even significant damage. This is why the IWGDF recommends regular foot examinations and risk-based screening. [41]

"It's enough to just smear your feet with foot ulcer cream." Cream can be part of skin care, but it doesn't eliminate venous reflux, ischemia, or mechanical pressure on the diabetic foot. [42]

Key points from experts

Sicco A. Bus, PhD, is Professor of Clinical Biomechanics at Amsterdam UMC and Director of Research on Lower Extremity Biomechanics and Prevention of Diabetic Foot Complications. Amsterdam UMC also lists him as the Chair of the IWGDF Working Group on Ulcer Prevention and Foot Offloading. [43]

The IWGDF 2023 guidelines, of which Sicco Bus is a key contributor, focus on preventing diabetic ulcers, not on a single device or drug, but on a combination of high-risk foot identification, regular examination, care education, appropriate footwear, treatment of pre-ulcer lesions, and comprehensive follow-up.[44]

Eva Maria Valesky is Professor, Head of the Department of Phlebology and Deputy Medical Director of the University Wound Center at University Hospital Frankfurt. She is the first author of the 2024 guidelines of the German Society of Phlebology and Lymphology on venous ulcers. [45]

In this guideline, prevention of recurrence after venous ulceration includes continued medical compression, treatment of venous insufficiency, physical activity, patient education, and, in obese patients, weight normalization. This emphasizes that recurrence prevention should continue even after complete wound closure. [46]

Frequently Asked Questions

Is it possible to completely prevent trophic ulcers?

This cannot be guaranteed, as the risk depends on the severity of the underlying disease. However, for many patients, the risk can be significantly reduced by controlling venous hypertension or arterial disease, practicing proper foot care in diabetics, and promptly detecting pre-ulcer changes. [47]

Do I need to wear compression stockings for the rest of my life after a venous ulcer?

Long-term use is often required, as the underlying cause of venous hypertension may persist after wound closure. The duration and type of compression are determined by the condition of the veins, arteries, tolerance, and whether the venous pathology has been corrected. [48]

Is it possible to select the compression class yourself?

It is best to avoid this, especially if you have diabetes, known arterial disease, or symptoms of ischemia. It is important to consider your arterial blood supply and select the correct size. [49]

Does walking every day help?

For chronic venous disease, physical activity and calf muscle pump training are beneficial treatment and prevention strategies. However, the level of activity should be appropriate for the condition of the joints, heart, and arterial blood supply. [50]

Should I elevate my legs if I have varicose veins and swelling?

In cases of venous edema, elevation of the legs during rest may be a useful adjunct. It does not replace properly applied compression or correction of significant venous reflux. [51]

How often should you examine your feet if you have diabetes?

For those with increased risk, perform screenings independently, daily. Professional screening is performed with a frequency depending on the risk category: from annual screening for those with minimal risk to examinations every 1-3 months for the most vulnerable patients. [52]

Should a small blister be treated in a person with diabetes?

If there is neuropathy or another high risk of ulceration, the callus may be a pre-ulcerative lesion and requires attention. Trimming it yourself is dangerous; it is better to relieve pressure and have it professionally treated. [53]

Are special orthopedic or diabetic shoes helpful?

For people at increased risk, yes, if the footwear is properly fitted. After a history of diabetic plantar ulcers, the IWGDF recommends therapeutic footwear with proven plantar pressure reduction. [54]

Can varicose vein treatment prevent ulcers?

In some patients, this is indeed an important part of prevention. In cases of healed venous ulcers and confirmed superficial venous insufficiency, the ESVS recommends treatment of the affected veins to reduce the risk of recurrence. [55]

Is smoking really linked to ulcer risk?

In peripheral arterial disease, continued smoking is a risk factor for ulcers and amputations and also contributes to the progression of vascular disease. Smoking cessation is part of modern treatment for peripheral arterial disease. [56]

Main

Prevention of trophic ulcers is primarily the prevention of nutritional deficiencies and tissue damage, rather than the prophylactic application of ointments.

After a venous ulcer, the most proven strategy involves long-term compression and assessment of the possibility of eliminating pathological venous reflux. In diabetes, regular foot examinations, detection of neuropathy and arterial disease, appropriate footwear, and early treatment of pre-ulcer lesions are essential. Peripheral arterial disease requires preventive foot care and comprehensive vascular treatment.

The most useful rule of thumb is to avoid waiting for an open wound to develop. Persistent swelling, venous changes in the skin, a callus on an insensitive diabetic foot, a small, non-healing wound, or signs of decreased arterial blood flow provide an opportunity to intervene before a chronic ulcer develops.