Arterial Ulcer
Reviewed by Andrew Schox, BSc(Hons) PGradDipPod MPod, November 2026
Poor blood flow to the foot or lower leg can leave a wound that won't heal. Narrowed leg arteries leave the skin short of oxygen, so it breaks down. The main symptom is a painful sore on the foot or around the ankle, often worse at night. It isn't clear how common it is. How well it does depends on restoring blood flow and managing the circulation problem behind it. Warning signs include severe foot or leg pain that does not go away even when resting, a foot that changes colour and becomes cold and numb, and a wound turning black and beginning to smell.
What is it?
An arterial ulcer is an open wound on the foot or lower leg. It happens when the skin isn't getting enough blood. The arteries (the blood vessels that carry blood to your legs and feet) have become narrowed or blocked, so the skin is starved of oxygen and nutrients and begins to break down.
It is part of peripheral arterial disease, or PAD, which means narrowed leg arteries, often called poor circulation. PAD is the most common cause of these ulcers. It can also cause cramping leg pain when walking, pain at rest, and, in severe cases, gangrene (dead tissue).
Who does it affect?
Smoking and diabetes are the two main risk factors for PAD, and so for arterial ulcers. Atherosclerosis (fatty deposits that narrow the arteries) is also linked to high blood pressure, heart disease and rheumatoid arthritis.
About half of people with diabetes and a foot ulcer also have PAD. In those people, PAD raises the risk of serious problems in the foot and leg, and of heart and blood vessel problems.
It isn't clear how common arterial ulcers are. Arterial ulcers may make up roughly 1 in 10 leg ulcers, though this is only a rough estimate and isn't clear.
Signs and symptoms
Arterial ulcers most often sit on the foot or around the ankle, and sometimes on the lower leg. Common spots are the toes, the heel, the sides of the foot and other bony areas. The wound often has little or no fluid or discharge.
These ulcers are often very painful. The pain is usually worse at night in bed, because lying flat reduces the blood reaching your feet. It often eases when you hang your leg over the side of the bed or sit or stand.
Your feet and legs may feel cold and look pale, whitish or bluish, and shiny. The skin may change colour when you raise and lower the leg, and the pulses in your foot may be weak or hard to find. Arterial ulcers can also get infected, but treating the infection alone usually won't heal them.
What causes it?
Over time, fatty deposits build up inside the leg arteries. This is called atherosclerosis. The deposits narrow the arteries and restrict the blood flow to your leg.
When too little blood reaches your foot or lower leg, the skin and the tissue under it don't get enough oxygen. This is called ischaemia. The skin can then break down and form an ulcer.
When blood flow becomes severely restricted, it is called chronic limb-threatening ischaemia. This is the end stage of PAD, with severe pain at rest and loss of tissue.
How is it diagnosed?
Your podiatrist or doctor will test your circulation rather than rely on feeling for pulses, which can be unreliable. The main test is the ankle-brachial index (ABI). It compares the blood pressure at your ankle with the pressure in your arm. Any sign of poor circulation calls for this test.
In people with diabetes or kidney disease, hardened artery walls can push the ABI up falsely, so a normal result doesn't rule out PAD. Your podiatrist may add toe pressures and a Doppler test (an ultrasound check of blood flow in the foot). The results are read together with your history and how the ulcer is healing.
If your circulation tests are normal but the wound still isn't healing, your team should look for another cause.
Treatment
The main treatment is to restore blood flow to the foot, not only to dress the wound. A vascular team (specialists in blood vessels) matters most.
Looking after it at home
Don't use compression bandages unless a health professional has confirmed they are safe. They aren't safe when blood supply to the leg is reduced.
Structured exercise, supervised or community-based, is a core part of PAD care.
Your doctor may prescribe medicines for your circulation and heart risk, such as cholesterol-lowering, antiplatelet (makes blood less sticky) or blood pressure medicines, and will review them. PAD can't be cured, but it can be managed.
Treatment from your podiatrist
Your health professional can check your circulation. If an arterial ulcer is suspected, or you have a leg ulcer with PAD, the ulcer is linked to a problem with the blood supply to the leg, as arterial ulceration is part of PAD. A very low ankle-brachial index (below 0.5) indicates a significant reduction in blood flow to the leg.
Other options
If the ulcer isn't improving, ask for a repeat vascular review rather than only changing dressings. Which dressings suit arterial ulcers isn't clear yet.
Medicines don't replace restoring blood flow, and do less for the leg if the arteries can't be reopened. Not everyone with severe poor circulation may need a procedure to restore blood flow, and it isn't clear yet how non-surgical care compares with having a procedure or which approach is best. Discuss your goals, pain and quality of life with your team.
Surgery
Revascularisation (a procedure to restore blood flow) is the cornerstone of preventing limb loss in severe PAD. Angioplasty uses a balloon to open a narrowed or blocked artery. Bypass surgery makes a new route around a blockage too large for a balloon, and endarterectomy clears a blockage. For an open ulcer, balloon angioplasty may be preferred because of the risk of graft infection. An experienced specialist team should make these decisions.
Recovery
Healing depends on how much blood reaches your foot. An ulcer is often a sign of advanced PAD, which is linked with serious illness. In people with diabetes, PAD makes a foot ulcer less likely to heal and raises the risk of amputation.
PAD can worsen over time. About 15 per cent of people with cramping leg pain when walking develop chronic limb-threatening ischaemia, which carries a high risk of limb loss and affects walking and quality of life. Poor nutrition is linked with a higher risk of amputation and death.
A healed ulcer doesn't mean your circulation problem has gone, so checks continue. It isn't clear how often ulcers heal or come back.
Preventing it
Stopping smoking is the single most important change you can make. A quit-smoking service can offer practical help with stopping smoking.
Take the medicines your doctor prescribes for your cholesterol, blood clotting and blood pressure. Walking also helps. Exercise can ease PAD symptoms, so ask your team about a supervised or home-based walking programme that suits you.
If you have diabetes, make foot care part of your diabetes self-care plan, made with your health care team. Your podiatrist may be part of that team.
What can make it serious?
- You have a foot wound, ulcer or infection and also feel very unwell, with confusion or slurred speech, severe shivering or muscle pain, severe breathlessness, mottled or discoloured skin, or little or no urine (possible sepsis).
- Your leg or foot suddenly turns cold and pale, with pain or numbness, or you suddenly can't move it.
- You have diabetes or poor circulation and signs of infection in your foot, toe or nail, such as redness, warmth, swelling, pus, a bad smell or more pain.
- You have diabetes, poor circulation or reduced feeling in your feet and notice a new wound, sore, blister or colour change on your foot, or a sore that isn't healing.
- You have constant pain in your foot or toes that is worse at night or when your legs are raised, and eases when you hang your leg down (this can be a sign of poor circulation).
- The skin on your toes or foot turns dark or black, or a wound turns black and smells bad.
- Your foot ulcer is being treated but isn't getting better (ask about a review by the foot team).
Frequently asked questions
Can an arterial ulcer heal on its own?
Healing depends on how much blood reaches your foot. Treating an infection or caring for the wound surface alone usually won't heal it, which is why a wound like this may be caused by a circulation problem rather than the skin alone.
How is an arterial ulcer different from a venous ulcer?
The two types are treated differently. Compression that suits some other leg ulcers isn't suitable when the blood supply is reduced, so a health professional needs to work out which type you have before anything is wrapped around your leg.
Will I need a procedure to open my arteries?
Procedures to restore blood flow are the main way to protect the limb in severe PAD. Some people may not need one, though it isn't clear yet how treatment without a procedure compares with having one. Your vascular team can talk through your options with you.
Does stopping smoking really make a difference?
Yes. It is the single most important change for people with PAD, because carrying on smoking is likely to make symptoms worse. A quit-smoking service can give you practical support.
Further reading
This is general information, not medical advice. For advice about your own situation, see your health professional. For urgent advice, call your local health advice line or emergency number, or go to an emergency department.