Differentiating Arterial vs. Venous Ulcers

Course Highlights

  • In this course we will learn about arterial, venous, and neurotrophic ulcers, and why it is important for nurses to identify the various signs, symptoms, complications, and treatments of each.
  • You’ll also learn the basics of both diagnostic and non-diagnositic testing for ulcers.
  • You’ll leave this course with a broader understanding of the differences between arterial vs. venous ulcers.


Contact Hours Awarded: 1.5

Course By:
Carlana Coogle

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The following course content


This learning module will discuss the three most common types of leg/foot ulcers: venous stasis ulcers, neurotrophic (diabetic), and arterial (ischemic ulcers). Additionally, we will cover the main differences between arterial vs. venous ulcers, as this can become quite confusing at times. Following, we will review the circulatory system’s pathophysiology, ensuring an understanding of blood flow and the vital role arteries and veins have on circulation. Lastly, we will discuss the presentations of each type, the common causes, risk factors, generalized treatments, and patient education.  

As you work your way through the section questions, I hope you will be able to recall some patients you have cared for and gain a better understanding of why the wounds presented as they did.  

Okay, let’s get started!  

Circulatory Pathophysiology Review 

Pulmonary circulation is responsible for the circulation of oxygen-poor blood from the heart’s right ventricle going to the lungs via the pulmonary artery and then returning oxygen-rich blood back to the heart’s left atrium via the pulmonary vein (3). 

Systemic circulation is responsible for circulating the oxygenated blood from the heart to all the body systems. 

The vascular system supplies oxygen to the body and removes water through 5 types of blood vessels (arteries, arterioles, veins, venules, and capillaries (the smallest vessels- linking arterioles and venules). 

Vessel Type  Function  Features 
Arterial System 
  • High-pressure, transports blood to from heart to smaller arteries/arterioles 
  • No valves the high pressure from heart keeps blood flowing 
  • Low-pressure, transports blood from venules to heart 
  • Valves present to keep blood flowing toward the heart 
  • Diffusion of gases and transfer of nutrients and waste products between blood and tissues 
  • Smallest and most numerous of all blood vessels 
  • Connect the arteries and veins to allow for the exchange 


Venous Stasis Ulcers 


Venous ulcers begin due to capillary bed distention that is caused by increased pressure; causing a leakage of fibrinogen and eventually impeding the delivery of oxygen and nutrients, resulting in a hypoxic injury. Typically, this leads to fibrosis and then ulcerations. 

These ulcers are often chronic, and patients often battle from weeks to years. Cleveland Clinic states 500,000 to 600,000 people in US are affected by venous ulcers, and venous ulcers account for 80-90% of all leg ulcers. The financial burden of venous ulcers is estimated to be $2 billion per year in the United States (2).  

A common mishap is the confusion between arterial vs. venous ulcers, so let’s break them down individually by signs and symptoms, complications, risk factors, treatments, and patient education.  

Signs and Symptoms (1) 

  • Wounds are usually located below the knee, can be one or both legs 
  • Shallow painful ulcerations usually over the medial malleolus 
  • Wound bed is beefy red and often has fibrin present 
  • Borders are irregular, surrounding tissue is often discolored and swollen (can even feel warm) 
  • Skin usually appears shiny and tight depending on edema  
  • Elevation improves edema and relieves pain 
  • Normal pulses are present  


  • Cellulitis  
  • Osteomyelitis 
  • Sepsis  
  • Amputation  

Risk Factors

  • Poor Circulation  
  • Venous insufficiency 
  • Clotting disorders 
  • Diabetes 
  • Renal failure 
  • Elevated cholesterol and triglycerides 
  • Lymphedema 
  • Obesity 
  • Infections 
  • Smoking 
  • Uncontrolled hypertension 
  • Inflammatory diseases (vasculitis, lupus, etc) 


Compression treatments are the most widely used treatment for venous stasis ulcers. This could include ace wraps, compression stockings, and Unna boots. 

Dressings are ordered based on wound characteristics (do we need to dry the wound or add moisture). Dressings may include: 

  • Moist to moist dressings 
  • Hydrogels/hydrocolloids 
  • Alginate dressings 
  • Collagen wound dressings 
  • Debriding agents 
  • Antimicrobial dressings 
  • Composite dressings 

Patient Education

  • Inspect your feet and between your toes, look for cracks, cuts, blisters, redness, increased warmth, calluses 
  • If you are a diabetic, see a podiatrist on a regular basis 
  • Apply a lanolin-based cream to your legs and feet to prevent dry skin and cracking. Do notapply lotion between your toes or on areas where there is an open sore or cut.  
  • If you have an open area, gently wash with mild soap and water daily, washing helps loosen dead skin and debris 
  • If you cut your own toenails, do it after bathing when nails are soft and cut straight across 
Quiz Questions

Self Quiz

Ask yourself...

  1. What assessment findings would you expect to see in a patient with venous stasis ulcers? 
  2. What types of nursing interventions could you recommend to a patient with vascular disease but no active ulcers present? 
  3. What symptoms would you teach a patient to report to their provider related to worsening venous stasis ulcers? 

Arterial (Ischemic) Ulcers 


The two most common causes of arterial (or ischemic) ulcers are progressive atherosclerosis and emboli. Other pathologic processes can cause arterial obstruction, leading to arterial insufficiency symptoms, but remember, the reason for all the issues is due to reduced blood flow which leads to ischemia of the affected extremity. Arteries carry the oxygen and nutrient-rich blood supply to the extremities and this process is blocked by some physiological reason (5).  

Since we now know how to identify and treat venous ulcers, we are one step closer to understanding the main differences between arterial vs. venous ulcers, let’s keep going! 

Signs and Symptoms

  • Wounds are usually located distally on the dorsum of the foot or toes 
  • Wound bed is usually grayish in color, and granulation tissue appears unhealthy 
  • Little to no bleeding is noted 
  • Painful, especially at night when supine-putting leg dependent will relieve pain (opposite of venous ulcers) 
  • Pale skin, hairlessness 
  • Diminished pulses, cool to touch 
  • Intermittent claudication- is a reproducible discomfort of a defined group of muscles (usually lower legs) that is induced by exercise and relieved with rest (2) 

Remember, the extremity is not getting perfusion which limits, oxygen and nutrients! 


  • Infection/gangrene 
  • Tissue necrosis 
  • Amputation 

Risk Factors

  • Diabetes mellitus 
  • Age (risk increases after 40) 
  • Arteriosclerosis  
  • Vasculitis  
  • Foot deformity and callus formation which causes areas of high pressure 
  • Obesity 
  • peripheral neuropathy 
  • Smoking 
  • Limited joint mobility/ any trauma to lower extremities  


Treatments vary, depending on the severity of the arterial disease, but the goal is to increase circulation. Ischemic wounds, unlike venous, are usually kept dry to reduce the risk of infection.  

  • Endovascular therapy, bypass surgery, revascularization 
  • Medications that cause blood vessels to dilate 
  • Modify contributing factors (smoking, weight, control DM, take meds as prescribed) 
  • Boot pumps  
  • Hyperbaric oxygen therapy (HBOT)  
  • Negative pressure wound devices (wound vacs)  
  • Monitor signs and symptoms of infection, ensuring no tunneling or tracking 
  • Amputation- last resort 

Patient Education

  • Examine feet (especially between the toes) and legs daily for any unusual changes in color or the development of sores  
  • Manage blood pressure, cholesterol, triglyceride, and glucose levels 
  • Quit smoking 
  • Avoid cold, caffeine, nicotine, and constrictive garments  
  • Walking (most doctors want these patients to walk daily) 
  • Take medications as directed  
  • Teach patient signs and symptoms of wound infection 
Quiz Questions

Self Quiz

Ask yourself...

  1. What assessment finding help you recognize an arterial vs. venous ulcer wound? 
  2. How would you explain in plain language to a patient why pain occurs in arterial wounds? 
  3. How would you explain the differences between arterial vs. venous ulcers to a colleague or nursing student? 
  4. How would you explain to a patient why smoking impedes wound healing? 

Neurotrophic (Diabetic) Ulcers 


Although it does not present as similarly between arterial vs. venous ulcers, neurotrophic ulcers are quite common. Neurotrophic or diabetic ulcers may have neuropathic, vascular, and immune system components. Most of these ulcers are caused by a hyperglycemic state due to diabetes (1). When patients are in a hyperglycemic state, it produces oxidative stress on nerve cells and leads to neuropathy, common in diabetic patients. As the nerve damage continues, it damages the nerve cell protein and leads to further ischemia, resulting in even more impaired healing for wounds. These cellular changes manifest in 3 ways: 

  1. Motor nerve damage- leads to an imbalance of flexors and extensors, anatomic deformities, and eventual skin ulcerations 
  2. Autonomic nerve damage- impairs sweat gland function leading to reduced moisture thus causing epidermal cracks and skin breakdown 
  3. Sensory nerve damage- reduced sensation thus patients do not feel pain with injury or ulcers (4) 

Vascular changes are also related to a hyperglycemia state which causes changes in the peripheral arteries. The endothelial cell changes lead to vasodilation resulting in poor perfusion, which leads to hypercoagulation in the peripheral arteries. All these changes lead to ischemia and increase the risk of ulceration (4). 

Immune changes that occur reduce the healing response; these patients have an increased T lymphocyte response, inhibiting healing. As you see these are complex patients that generally have multiple factors influencing their wound healing (4).  


Signs and Symptoms

  • Wounds are located at increased pressure points on the plantar surface and surrounded by callus 
  • Appearance at wound base is variable, depending on patient’s circulation, may appear pink/red or brown/ black 
  • Wound borders have a punched-out appearance, while the surrounding skin is often calloused 
  • Patient may complain of tingling, numbness or burning 
  • Undermining is often present along the wound edges 


  • Osteomyelitis 
  • Infections 
  • Amputation 

Risk Factors

  1. Previous lower extremity amputation 
  2. History of a foot ulcer 
  3. Anatomic foot deformity 
  4. Peripheral vascular disease 
  5. Diabetic nephropathy  
  6. Diabetes especially with poor glycemic control 
  7. Smoking 
  8. Hypertension 


  • Avoiding pressure and weight-bearing on the affected leg 
  • Regular debridement is necessary to allow healing 
  • Autolytic debridement:  lysis of necrotic tissue by the patient own WBC and enzymes (occurs naturally) most of the time this is not enough 
  • Chemical debridement: a topical medication prescribed by provider; examples include: Collagense (Sanytl) Papain with urea (Accuzyme, Gladase) 
  • Mechanical debridement: wet to dry dressings (not common as they are not selective), whirlpool treatments 
  • Sharp debridement: sterile scalpel to remove dead tissue 
  • Surgical debridement: operating room to remove dead tissue (6) 
  • Frequently, special shoes or orthotic devices must be worn 
  • Negative pressure wound devices (wound vacs)  
  • Hyperbaric oxygen therapy (HBOT)  

Patient Education

  • Avoid smoking 
  • Avoid going barefoot, even at home, especially on hot decks and hot sand 
  • Test water temperature before stepping into a bath 
  • See podiatrist regularly 
  • Wash feet in lukewarm water, dry thoroughly (including between the toes), and check feet daily for any skin breakdown 
  • Shoes should be snug, but not tight, and customized if feet are misshapen or have ulcers 
  • Change socks daily 
  • Avoid cold, caffeine, nicotine, and constrictive garments  
Quiz Questions

Self Quiz

Ask yourself...

  1. What is the biggest risk factor for the development of a neurotrophic ulcer? 
  2. What questions or assessments will you now do to ensure neuropathy is identified in your patient? 
  3. How can you ensure your patient understands vasoconstriction and vasodilation and the impact on wound healing?  

Diagnostic Tests for Ulcers (6) 

Diagnostic Test  Possible findings the test can identify 
X-ray– easy, and cost effective 
  • Fracture, bone deformities, calcifications, and gangrene. 
  • Used for non-invasive vascular imaging (eg, B-mode, duplex). 
  • Can evaluate the location and extent of vascular disease, arterial hemodynamics, and lesion morphology. 

CT scanimaging that combines x-rays with computer technology to produce cross-sectional images of the scanned body part 



  • A CT scan lets your doctor see the size, shape, and position of structures that are deep inside your body. 
  • Used to diagnose infections, muscle disorders, fractures, tumors, blood vessel issues. 
  • Angiography is now commonly applied to the evaluation of visceral arterial and peripheral artery disease  
MRI- imaging that produces cross-sectional images of the body without radiation, it uses magnetic fields and radio waves for more detailed images 
  • Can alter the contrast of images and provides more details in the soft tissues, can identify same things as a CT. 
Duplex imaging 
  • Can be used to evaluate the vasculature preoperatively, intraoperatively, and postoperatively for stent or graft surveillance; it is also very useful in identifying proximal arterial disease. 
Ankle-brachial index (ABI) 
  • The ABI is the ratio of the ankle systolic blood pressure divided by the brachial systolic pressure detected with a Doppler probe. In patients with zero or mild to moderate symptoms, an ABI of <0.90 has a high degree of sensitivity and specificity for PAD, using arteriography as the reference standard (1). 
Buerger Test 
  • Non-invasive test can be done at bedside or in-office, with elevated extremities; the leg will become pale or with legs dependent first they become pale then become red. 
Wound Cultures- obtained to identify possible micro-organisms  
  • Infections must be treated for wounds to heal. 
Laboratory Panels- CBC, CMP, albumin, LFT, Thyroid panel 
  • Labs indicate electrolyte imbalances, anemia, infection, renal disease, malnutrition, liver disorders, thyroid disorders, and many other items. 

Non-Diagnostics for Ulcers

Complete Medical and Social History

Medical and social history are key in identifying current contributing factors that could be playing a role in wound healing. 

Wound Consultant

Often done to ensure the best treatment is being done, and often wounds are followed by a wound care center program ensuring frequent assessments and continual monitoring.  

Nutrition Consultant

Adequate nutrition is needed for wound healing, and a registered dietician is often consulted to ensure adequate protein and other nutrients are part of the patient’s plan of care.  

Quiz Questions

Self Quiz

Ask yourself...

  1. Would an ABI of 1.5 indicate the patient may have calcified vessels and would likely be ordered more vascular studies? 
  2. How will your wound assessment change from the information learned in this module? 
  3. If you had diminished pedal pulses and the patient complained of pain with elevation, what type of disease process is happening? 
  4. What are some focused questions you can now ask your patient with a wound that will assist in determining the possible cause? 
  5. What are some patient education elements that you can teach your patient no matter what the cause of the wound is?  


Understanding the pathophysiology of venous stasis ulcers, neurotrophic (diabetic), and arterial (ischemic ulcers) along with the circulatory system will assist you in identifying key differences and similarities in these types of wounds. As a nurse, the ability to differentiate the signs, symptoms, complications, and treatments of all ulcers, specifically arterial vs. venous, is an invaluable skill to possess. It is important for patients to understand the “why” in their disease process. I believe that being able to connect and explain things in simple, plain language to patients increases their engagement and empowers them to take control of their disease or chronic condition. 

References + Disclaimer

  1. Takahashi P. Chronic Ischemic, Venous, and Neuropathic Ulcers in Long-Term Care. Annals of Long-Term Care. Published September 5, 2008. Accessed August 22, 2019. 
  2. Cleveland Clinic (2020). Leg and Foot Ulcers. Retrieved 3/20/21 from: 
  3. Gaberiel, A., Camp, M., Paletta, C., Massey, B. (2020, June). Vascular Ulcers. Medscape. Retrieved from 
  4. Aumiller, Wade D. PhD; Dollahite, Harry Anderson MD Pathogenesis and management of diabetic foot ulcers, Journal of the American Academy of Physician Assistants: May 2015 – Volume 28 – Issue 5 – p 28-34 doi: 10.1097/01.JAA.0000464276.44117.b1 
  5. London Health Sciences Centre. Venous Stasis & Arterial Ulcer Comparison. London Health Sciences Centre. Accessed August 22, 2019.  
  6. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135:e726. 

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