From Clinical guidelines — Diagnosis and treatment manual › Chapter 10: Medical and minor surgical procedures · Médecins Sans Frontières, Current online edition, 2026
MSF guidance on diagnosis, local and systemic treatment of chronic leg ulcers in tropical and resource-limited settings.
- Issuer
- Médecins Sans Frontières
- Edition
- Current online edition, 2026
- Audience
- Clinicians working in humanitarian, tropical and resource-limited settings
- Evidence
- Expert consensus based on MSF field experience
- Reviewed
- 22 Oct 2026 · GMJ
What this guideline says
GMJ summary
This MSF clinical guideline addresses the management of chronic leg ulcers, particularly common in tropical regions. Leg ulcers result from diverse aetiologies including vascular insufficiency, bacterial infections (leprosy, Buruli ulcer, phagedenic ulcer, yaws, syphilis), parasitic diseases (dracunculiasis, leishmaniasis), metabolic disorders (diabetes), and trauma. The guideline emphasises the importance of a thorough history and clinical examination, particularly neurological assessment, to identify underlying causes such as leprosy or diabetes-related peripheral neuropathy.
Management consists of daily local wound care (bathing in NaDCC solution, debridement, and application of appropriate antiseptics based on wound characteristics) combined with systemic treatment when indicated. Antibiotics are recommended for secondary bacterial infections and for early-stage phagedenic ulcers, with specific regimens of doxycycline or metronidazole provided. The guideline warns of potential complications including regional infections, septicaemia, tetanus, and long-term risk of skin cancer.
Complementary measures include leg elevation for venous/lymphatic insufficiency, tetanus prophylaxis, treatment of underlying causes, and consideration of skin grafting for extensive clean ulcers, particularly after surgical excision of phagedenic and Buruli ulcers.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Bathe the leg daily for 10 to 15 minutes in NaDCC solution and rinse in boiled water; remove necrotic and fibrinous tissue
- For clean ulcers with little discharge: apply 10% povidone iodine and vaseline
- For extensive oozing ulcers or multiple ulcers: use diluted povidone iodine (1/4 of 10% povidone iodine + 3/4 sodium chloride) for one minute then rinse to reduce transcutaneous iodine absorption
- For phagedenic ulcer in early stages: doxycycline PO 4 mg/kg once daily (children ≥8 years) or 200 mg once daily (adults), or metronidazole PO 10 mg/kg 3 times daily (children) or 500 mg 3 times daily (adults)
- Continue antibiotherapy for 7 days initially; if effective, continue with doxycycline or metronidazole based on clinical evolution
- Perform thorough neurological examination to identify peripheral neuropathy caused by leprosy or diabetes
- Elevate legs in cases of venous and/or lymphatic insufficiency
- Consider skin graft if ulcer is extensive, clean, red and flat; often necessary after surgical excision of phagedenic and Buruli ulcers
Local treatment by ulcer characteristics
Table extracted from the guideline
| Ulcer type | Treatment application |
|---|---|
| Clean ulcer, little discharge | 10% povidone iodine and vaseline |
| Dirty ulcer, little discharge | Silver sulfadiazine to limited area (monitor for systemic adverse effects) |
| Oozing ulcer | 10% povidone iodine alone |
| Extensive oozing ulcer or multiple ulcers | Diluted povidone iodine (1/4 of 10% + 3/4 sodium chloride/water) for 1 minute, then rinse |
Source: Médecins Sans Frontières, Leg ulcers — MSF Clinical guidelines. Reproduced in summary form.
From the guideline
Verbatim
“The history of the disease and a complete clinical examination (paying particular attention to the neurological examination to determine if there is a peripheral neuropathy caused by leprosy or diabetes) usually leads to an aetiological diagnosis.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As Editor-in-Chief of the Georgian Medical Journal and Chair of the Public Health Institute, I recognise the growing burden of chronic leg ulcers in Georgia, particularly among our expanding diabetic population within the Universal Healthcare Programme. This MSF guideline provides a practical, resource-appropriate framework for wound assessment and management that aligns well with primary and secondary care capacity in Georgia and neighbouring Armenia and Azerbaijan. I would stress to Georgian clinicians the critical importance of neurological examination to identify diabetic or leprosy-related peripheral neuropathy, as early detection of underlying causes prevents progression and complications. The main implementation challenge in our context will be ensuring consistent availability of wound care supplies such as NaDCC solution and appropriate antiseptics across rural health centres, and integrating this systematic approach into existing diabetes and vascular disease management protocols rather than treating leg ulcers as isolated dermatological problems.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 22 Oct 2026
Applicability
Georgia and the South Caucasus
This guideline has direct relevance for Georgia and the South Caucasus, where chronic leg ulcers related to diabetes and vascular insufficiency are increasingly common due to the noncommunicable disease burden. Whilst tropical neglected diseases such as Buruli ulcer and dracunculiasis are not endemic in the region, the systematic approach to wound assessment, local care protocols, and antibiotic stewardship for secondary infections are universally applicable. National wound care programmes in Georgia would need to adapt the aetiological spectrum to reflect regional prevalence (emphasising diabetic foot ulcers and venous insufficiency over tropical infectious causes), ensure availability of essential wound care supplies including NaDCC solution and appropriate antiseptics, and integrate this guidance with existing diabetes and vascular disease management protocols within the Universal Healthcare Programme.
Questions this guideline answers
Quick answers
When should antibiotics be given for leg ulcers?
Systemic antibiotics are indicated for secondary bacterial infections (abscess, lymphadenopathy, adenitis, osteomyelitis, erysipela, pyodermitis) and for phagedenic ulcers in early stages. They are often ineffective in chronic phagedenic ulcers. Antibiotics are not routinely given for uncomplicated leg ulcers.
How should I dilute povidone iodine for extensive ulcers?
For extensive oozing ulcers or multiple ulcers, dilute 1/4 of 10% povidone iodine with 3/4 of 0.9% sodium chloride or clean water, apply for one minute, then rinse with 0.9% sodium chloride or clean water. This reduces the risk of transcutaneous iodine absorption.
What is the antibiotic regimen for phagedenic ulcer?
Use doxycycline PO (4 mg/kg once daily for children ≥8 years; 200 mg once daily for adults) or metronidazole PO (10 mg/kg 3 times daily for children; 500 mg 3 times daily for adults). If effective after 7 days, continue treatment with duration varying according to clinical evolution.
When should skin grafting be considered?
Skin grafting should be considered if the ulcer is extensive, clean, red and flat. Skin grafts are often necessary after surgical excision to heal phagedenic and Buruli ulcers.
Related on GMJ
Interconnected resources
Dictionary of Public Health
Drugs A–Z
Conditions A–Z
GMJ News coverage
Same guideline
- Pyomyositis — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures
- Cutaneous abscess — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures
- Burns — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures
- Treatment of a simple wound — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures
- Dressings — MSF Clinical guidelinesChapter 10: Medical and minor surgical procedures
- Abnormal uterine bleeding (in the absence of pregnancy) — MSF Clinical guidelinesChapter 9: Genito-urinary diseases
Other guidelines on this topic
- Pyomyositis — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelines
- Cutaneous abscess — Clinical guidelines — Diagnosis and treatment manual — MSF Clinical guidelines
- Venereal warts — MSF Clinical guidelines
- Other investigations — MSF Tuberculosis
- Abnormal vaginal discharge — MSF Clinical guidelines
- Issuer
- Médecins Sans Frontières
- Guideline
- Clinical guidelines — Diagnosis and treatment manual
- Chapter
- Chapter 10: Medical and minor surgical procedures
- Type
- Clinical guideline (chapter)
- Edition
- Current online edition, 2026
- Status
- Current
- Published
- 2026-10-14
- Scope
- Diagnosis and treatment of chronic leg ulcers in resource-limited and tropical settings
- Audience
- Clinicians working in humanitarian, tropical and resource-limited settings
- Evidence
- Expert consensus based on MSF field experience
- Record history
- Created 22 Oct 2026 · updated 22 Oct 2026 · next check Apr 2027
Médecins Sans Frontières. Leg ulcers. In: Clinical guidelines — Diagnosis and treatment manual [Internet]. Paris: MSF; 2026 Oct 14 [cited 2026 Oct 14]. Available from: https://medicalguidelines.msf.org/GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
Was this article helpful?
