Venous vs. Arterial Ulcers: What’s the Difference?

How can you remember the difference between venous vs. arterial ulcers? Visualization is a good place to start.

Venous vs. Arterial: What’s the Difference?


One of the most basic lessons in wound care education is learning the characteristics of venous vs. arterial ulcers – and being able to tell the difference between the two. It can be downright tricky – especially for new clinicians. Fortunately, we have a handy technique for remembering what to look for. And it all starts with visualizing what causes the wound in the first place.

Venous Ulcers: It’s About Pooling Blood

When your patient has venous insufficiency, what’s going on? It’s not a problem with blood flow, it’s a problem with blood return. When the blood can’t get back up to the heart, it pools in the lower leg.

With that in mind, what will you notice when looking at a venous ulcer? For starters, there will be scaly skin around the wound, and weepy edema from the pooling of fluids and plasma. The extra blood also pushes red blood cells out of the capillaries, and as those red blood cells release iron, they cause the purplish/brown color known as hemosiderin staining.

As for the ulcer, you’ll see irregular wound margins and a shallow wound on the mid to lower leg (the medial malleolus), where the valves fail to allow the return of blood. They seldom occur below the ankle or above the knee. In line with the theme of “too much”, there will be moderate to heavy drainage (aka exudate). There may be necrotic tissue. The viable tissue in the wound bed will be red, because again, the blood pools in that area. The bottom line? If you’re able to pause and envision the whole process, then a red wound with plenty of drainage makes perfect sense.

Arterial Ulcers: Think of a Dying Garden

Now let’s talk about arterial ulcers, which are the opposite of venous ulcers. When your patient suffers from arterial disease, blood return is not the issue. Instead, we have a problem with the flow – blood that can’t get down to the area in question. As a result, the surface will look more like a “barren wasteland.” Think of it as a garden: if you can’t transport water and nutrients to the plants (in this case, tissues), everything will dry up and die.

Keeping the garden analogy in mind, what will you notice when looking at an arterial ulcer? You’ll see areas where necessary fluids and nutrients just aren’t getting through. There will be little exudate, and the surrounding skin is more likely to be cool to the touch, pale, cyanotic (bluish due to lack of oxygen), and hairless.

Within the wound bed, you may find necrotic (dead) tissue as well as tissue that is pale because of the lack of blood. The wound itself will be deep and regular in shape, with a round, “punched-out” look. Arterial ulcers most often occur on the outer ankle (lateral malleolus), and around the toes including the tips, between the toes, and the phalangeal heads—areas that are subject to trauma and rubbing. The bottom line? If you recall that a lack of blood flow is the issue (through visualization), it’s easier to remember that this type of ulcer occurs on the farthest extremities.

Find out more about venous, arterial and neuropathic ulcers – including a fuller list of descriptions, characteristics, assessment and treatment – from our Lower Extremity Ulcers Best Practice Guide.

Lower Extremity Guide Download

(Click here to get our Guide to Lower Extremity Ulcers)

Real-World Assessment: the ABI

Congratulations are in order! You have learned how to remember the characteristics of venous vs. arterial ulcers.  As you make a visual assessment of lower extremity ulcers, keep our tips in mind. But that’s only the first step. Lower extremity ulcers can have mixed causes, and not every venous or arterial ulcer will follow the exact descriptions above.

That’s why the Ankle Brachial Index (ABI) is the next step, and an absolute must for proper diagnosis and treatment. The ABI will tell us if the patient has adequate blood flow, and help us determine how much compression we can safely apply. (Learn more about this “gold standard” diagnostic tool in the WCEI blog, Why ABI?)

Do You Know the Difference?

Did you already know how to tell the difference between venous and arterial ulcers? If so, what helped you learn to distinguish between the two? Do you have additional tips or advice to share with others? We welcome your feedback – please leave your stories or ideas in the comment section below.


Wound Care Education Institute® provides online and onsite courses in the fields of Skin, WoundDiabetic and Ostomy Management. Eligible clinicians may sit for the prestigious WCC®, DWC®, OMS and NWCC™ national board certification exams through the National Alliance of Wound Care and Ostomy®(NAWCO®). For details, see


DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

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