Compression therapy is the most frequently single therapeutic approach. It promotes symptoms improvement such as pain or heaviness in legs and prevents lower limb edema or allows its resolution, therefore favoring ulcer healing [15]. The available compression methods are: compression socks, multi wraps, bandages, and pneumatic compression [15]. A systematic review showed that compression with elastic stockings can prevent the recurrence of venous ulcers although not with strong level of evidence [19]. All compression methods are contraindicated in the presence of significant peripheral arterial disease, unless the treatment is authorized by a vascular surgeon , based on the ankle-brachial index [15].

Medications known as phlebotonic drugs are a heterogeneous group of drugs (e.g., rutosides, hidrosmine, diosmine, calcium dobesilate, chromocarbe, centella asiatica, disodium flavodate, french maritime pine bark extract, grape seed extract, and aminaftone). A systematic review with 44 controlled, prospective and randomized studies, the conclusion was that there is no current evidence of its efficacy in cases of chronic venous insufficiency, requiring more clinical trials [20].

Surgical options should be considered in patients with nonhealing venous ulcers despite maximal medical effort. Invasive and surgical options may also be considered in patients who are unable to comply with compression therapy [21]. Nonoperative management of venous ulcer, including compression, elevation, and skin care, is clearly beneficial, such therapy does not correct the underlying pathology [22].

Interventional treatment of superficial venous incompetence can be accomplished by techniques that result in removal, ablation, or ligation of the refluxing venous segment (evaluated by venous duplex ultrasound) [23].

Surgery should be individualized according to the patient’s preoperative evaluation. A combination of ligation, axial stripping, and stab phlebectomy may be applied as needed to the great saphenous vein, small saphenous vein, tributary veins, and perforating veins [23].

A systematic review showed that open surgery can improve healing of venous ulcers, but the level of evidence is low, since the comparison was with observational studies [24].

The approach of deep venous system is more complex and includes techniques such as valve repair, valve transplantation, and venous shunts. The recommendation and the results of these techniques are highly controversial, and they are not routinely indicated in daily practice [15].

Endovenous minimally invasive techniques include: (a) endovenous laser and radiofrequency ablation, which promote physical damage to the saphenous vein, occluding it; (b) ultrasound-guided foam sclerotherapy, which promotes chemical occlusion of varicose saphenous and other veins and leads to correction or reduction of venous pressure, allowing the healing of ulcers [15]. Current evidence does not show superiority of endovascular interventions when compared to the isolated compression therapy [24].

Arterial ulcers are caused by the lack of tissues oxygenation secondary to arterial obstruction of the lower limbs. The most common cause is atherosclerosis in about 90 % of cases [25].

Prevalence of peripheral arterial disease in the United States is estimated at 3–5.5 %, and rises to 10–18.2 % in the population over 70 years of age [26]. Of these, 1–3 % will have peripheral ulcer throughout lifetime [27]. Arterial ulcers account for about 4–10 % of lower limb ulcers. The incidence increases to almost 20 % if mixed ulcers are included [2, 10, 28]. Studies show that these patients have a risk of major limb amputation ranging from 25 to 40 % after 1 year if not revascularized [29, 30].

Decreased arterial blood flow leads to ischemia and impaired tissue perfusion. At first, manifesting only during exercise (intermittent claudication). With the progression of the disease, this poor perfusion occurs even at rest, leading, in advanced stages, to necrosis of the underlying dermis and other tissues [25, 31].

The intense pain draws attention in arterial ulcers . Its intensity increases after raising the foot, improving with the use of potent painkillers or keeping the foot down [25, 30, 32].

Ulcers can occur spontaneously or after minor local trauma. It is manifested with necrosis, without granulation tissue (Figs. 17.2 and 17.3). The wound bed is pale, dry, and the edges are irregular [27]. In the presence of secondary infection, there is humidification of necrotic and surrounding tissues, with exudative secretion and stench, condition called wet gangrene [33].

Unlike venous stasis ulcers, arterial ulcers are typically located below the ankle, usually at the distal parts like toes and forefoot [34]. Another common presentation is in bedridden or immobilized patients who develop pressure ulcer in areas of unrelieved pressure, especially in heels [33, 35], but can occur anywhere else in the foot after a local trauma. They can be shallow or deep, with involvement of tendons, muscles, and bones. Arterial ulcers do not heal due to insufficient blood supply. The patient may have other signs of chronic ischemia, such as low skin temperature and reduced peripheral perfusion, thin, pale, and dry skin with no hair and nail dystrophy associated [25, 33].

Diagnosis is clinical. Physical examination shows absence of palpable pulses in the limb. For the objective confirmation of the disease, the ankle-brachial index must be performed, and it is usually under 70 mmHg [27, 36].

Treatment of arterial ulcer is complex and leaded by the vascular expert. These ulcers often require restoration of blood flow for wound healing and pain relief. Patients with atherosclerotic arterial ulcers should have medical treatment for systemic atherosclerosis: smoking cessation; strict control of blood pressure, glucose, and cholesterol levels; and use of antiplatelet drugs and statins [37]. Arterial revascularization can be performed by open surgery (artery bypass grafting) or endovascular surgery (percutaneous intervention) [38]. In patients with extensive trophic lesions or impaired limb functionality or those who, for medical reasons, are not candidate for revascularization, primary limb amputation can be the definitive and effective treatment [32]. The WIFi classification, based on wound characteristics, degree of ischemia and infection, helps to establish the risk of amputation and which patient will most benefit with revascularization [39].