This shows an advanced case of chronic venous ulceration with gross swelling, particularly of the left leg and deep pigmentation. It is due to chronic venous insufficiency but acute changes might well be due to recent deep vein thrombosis, exacerbating the chronic situation. Initial treatment would include bed rest and leg elevation with compression bandaging and local management of any skin ulceration. DVT prophylaxis should be given unless an acute DVT is present, when full heparinisation would be appropriate. Doppler scanning would be used to investigate for DVT and possibly venography, although this would be technically difficult and could exacerbate the condition.