Q: I have varicose veins in both my legs. Last year an ulcer developed in my left leg around the ankle. It continued for around 3 months, then I took Cloxacillin in intra vascular form, which gave me relief. Due to pigmentation, the whole area around the ankle has become black with some spots. Now again some ulcer is developing in the same leg, but at a different place. I am using crepe bandage to keep the area tight. I also keep my leg elevated at night, by putting a pillow beneath my leg. What precautions do I need to take to keep the disease under control? Can surgery cure the problem permanently? Some doctors say that the problem may crop up again even after the operation. Can I do exercises like jogging, running, skipping, etc? Which hospital or doctor can I consult to get best possible treatment?

A:I feel that you not only have varicose veins but most likely also have chronic venous insufficiency. This is the reason there is a constant problem of the breaking down of the skin and pigmentation. It may well be that the varicose veins have developed secondary to the condition of chronic venous insufficiency. As I do not have the detailed history of the patient available, I can only give the basic advice on how to stay free from symptoms and encourage the recurring ulcer to heal. My advice at present would be to have regular dressings done and also to have 3 layer or 4 layer bandaging of the leg done. The use of antibiotic should be only if the ulcer is infected and discharging pus. It may be worthwhile to have swab culture of the ulcer done and appropriate antibiotics given. If there is no infection and no discharge of pus then the mainstay is antiseptic dressing and layered bandaging. I also feel that walking, more than jogging, is to be encouraged until the ulcer has healed, but always after the bandage is in position. Walking without bandage is going to be detrimental. I am not sure what you mean by laser surgery, because laser is sometimes used as a term for minimally invasive surgery. I feel first a thorough assessment should be done, then only surgery would be contemplated and it is at that stage you could discuss or use the different modalities available. If there is chronic venous insufficiency from venous obstruction due to Deep Venous Thrombosis (DVT) then it may be unsafe to embark on the surgical option. On the other hand if the deep veins are sufficiently patent and ulcer has healed then I would strongly recommend surgery. Assessment by a Vascular Surgeon and a good venous duplex scan incorporating vascular doppler is mandatory. Long term relief would only be achieved when correct diagnosis is made by doing a duplex scan and dealing with the findings of that. The tentative approach will lead to the recurrence as mentioned in the letter. Regarding the hospital, I suggest that you take advice from a vascular surgeon in a major hospital and be guided by that.