Dermatology: Leg Ulcers

Question 1

Definition of a leg ulcer?

Answer 1

Any break in the skin of the lower leg, above the ankle, that has been present for more than 4 weeks

Question 2

Most common type of leg ulcer?

Answer 2

Venous in nature (60-80%)

Question 3

Types of leg ulcers?

Answer 3

Venous ulcers
Arterial ulcers
Mixed arterial-venous disease

Rheumatoid arthritis

Diabetic

Vasculitic

Malignant (skin cancer can present as a non-healing ulcer)

Hydrostatic (dependent limb)

Question 4

Questions to differentiate between arterial and venous ulcers?

Answer 4

Intermittent claudication?

Does elevation of their leg cause problems (do they find lying in bed difficult)? Does it disturb their sleep?

Both indicate ischaemic pain and arterial disease (venous pain is often neuropathic)

Is this the first time you have had an ulcer? (venous ulcers tend to recur

Is it itchy? (venous eczema/stasis dermatitis)

Question 5

Important PMH to consider?

Answer 5

Varicose veins

DVT

Clotting conditions

PVD

Arterial disease elsewhere

Diabetes

Question 6

Two things that should be noted when assessing an ulcer?

Answer 6

Position of ulcer and to consider whether trauma occurred

Measure surface area

Question 7

Why is the location of the ulcer of importance?

Answer 7

As long as the ulcer was not caused by trauma, the location may help determine the underlying disease process:

Venous ulcers tend to occur in the gaiter area, part. around the medial and lateral malleoli

If on the foot, the ulcer is very unlikely to be of venous origin and is probably arterial or diabetic (esp. around pressure site, like the heel, or where shoes rub due to neuropathy)

Question 8

Cutaneous signs of venous disease?

Answer 8

Haemosiderin deposition (brown staining of the skin) in the gaiter area

Varicose veins

Atrophie blanche - scarring on the lower leg after trauma; it is a sign of venous insufficiency

Lipodermatosclerosis - hardening of the fat layer of skin until it is woody and indurated; it is a sign of chronic venous insufficiency and other signs are hyperpigmentation, swelling and redness

Stasis dermatitis

Question 9

Appearance of venous ulcers?

Answer 9

Tend to have a shallow edge, like a beach

Question 10

Differentiating stasis dermatitis from cellulitis?

Answer 10

Often bilateral, whereas cellulitis is normally unilateral

Question 11

Treatment of stasis dermatitis?

Answer 11

Topical steroids

Emollients

Compression (MUST NOT DO THIS IF THERE ARE SIGNS OF ARTERIAL DISEASE)

Question 12

Ix for arterial disease?

Answer 12

Ankle-brachial pressure index (ABPI):
Normal: 0.8 - 1.3
Vascular disease: 1.5

With calcification, NO compression should be used; with vascular disease, compression can be used but carefully

Question 13

Other Ix when a leg ulcer presents?

Answer 13

Swab - ONLY if the ulcer is increasingly smelly/painful/exudative OR if it is enlarging

Bloods - FBC, LFTs, U+Es and CRP

Patch testing to previous ulcer treatments, e.g: bandages, dressings and creams

If indicated, do a duplex scan

Question 14

Treatment of venous ulcers?

Answer 14

AIM TO HEAL BY 12 WEEKS:
Control pain

ABPI

Non-adherent dressing

De-sloughing agent, if necessary, e.g: hydrogel or honey will remove the dead tissue/slough

4 layer compression bandaging

Leg elevation improves venous return

Question 15

How to carry out the 4 layer bandaging system (graduated compression)?

Answer 15

40 mmHg at the ankle and 25 mmHg below the knee (latex/ruber-free)

Non-adherent dressings are used and leg is padded to a CONE shape

Dressings are changed weekly, or as required

Question 16

3 types of dressings?

Answer 16

Simple, non-adherent dressings

Absorption: hydrocolloids, e.g: aquacel

Anti-bacterial: silver/iodine or manuka honey

Question 17

How can slough be treated?

Answer 17

Using maggots, which produce an enzyme that destroys necrotic tissue and does not harm healthy tissue

Zinc paste is around the wound when maggots are used and they are incinerated after

Question 18

Types of compression stockings?

Answer 18

Class 1 (weak) to 3 (strong)

Note: Even once ulcers are healed, compression stockings should still be used

Question 19

SIGN guidelines for compression use?

Answer 19

All patients with chronic venous leg ulcer should have an ABPI performed prior to treatment

Measurement of ABPI should be performed by appropriately trained practitioners

Compression should only be applied by staff with appropriate training

Question 20

Appearance of arterial ulcers?

Answer 20

Very sharp, cliff-like edges and appear to be “punched-out”

Question 21

How to differentiate an ulcer from a BCC?

Answer 21

BCC has a pearly appearance and telangiectasia

Question 22

How to clean ulcers?

Answer 22

Warm tap water and a soap substitute