Initial management of leg ulcers in community settings: proposals for a new algorithm for general practitioners

Venous leg ulcers (VLUs) affect 1% of individuals in developed countries, posing a significant public health challenge due to complications, patient disability and healthcare costs. While high compression (>40mmHg) is the gold standard, delays in vascular assessment often postpone the adapted treatment. The ankle-brachial pressure index (ABPI) is recommended to exclude peripheral arterial disease, but its availability and reliability may vary, particularly in patients with diabetes. Given these challenges, immediate mild compression (≤20mmHg) has been proposed as a first and safe interim approach before confirming venous aetiology through an assessment performed by a vascular physician. Studies show that mild compression prevents worsening venous hypertension and improves patient adherence compared to stronger compression. In this position paper, written by a group of expert physicians in the field of compression therapy, we propose a pragmatic approach to compression during the initial phase of leg ulcer management to optimise patient care and wound healing outcomes. Guidelines support early mild compression in the absence of arterial 'red flags' (most notably chronic limb-threatening ischaemia, CLTI), followed by an increase in compression once venous pathology is confirmed. In France, where only 6.5% of general practitioners perform ABPI, timely vascular assessment is often impractical, leading to delayed interventions. After clinical elimination of any contraindication(s) (such as CLTI, severe neuropathy and/or atypical ulcers with a lack of healing despite hypergranulation), an effective strategy should involve the immediate initiation of mild compression, conducting vascular assessment within 4-6 weeks, and transitioning to high compression if needed and if the patient is able to tolerate it. Hence, mild compression can also be beneficial for patients who do not tolerate high compression. Given the need to balance safety, efficacy and tolerance, mild compression can be a valuable first-line strategy before specialised intervention, and while waiting for ABPI measurement availability as part of a complete vascular assessment.