Dermatology: Leg Ulcers Flashcards
Definition of a leg ulcer?
Any break in the skin of the lower leg, above the ankle, that has been present for more than 4 weeks
Most common type of leg ulcer?
Venous in nature (60-80%)
Types of leg ulcers?
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)
Questions to differentiate between arterial and venous ulcers?
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)
Important PMH to consider?
Varicose veins
DVT
Clotting conditions
PVD
Arterial disease elsewhere
Diabetes
Two things that should be noted when assessing an ulcer?
Position of ulcer and to consider whether trauma occurred
Measure surface area
Why is the location of the ulcer of importance?
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)
Cutaneous signs of venous disease?
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
Appearance of venous ulcers?
Tend to have a shallow edge, like a beach
Differentiating stasis dermatitis from cellulitis?
Often bilateral, whereas cellulitis is normally unilateral
Treatment of stasis dermatitis?
Topical steroids
Emollients
Compression (MUST NOT DO THIS IF THERE ARE SIGNS OF ARTERIAL DISEASE)
Ix for arterial disease?
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
Other Ix when a leg ulcer presents?
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
Treatment of venous ulcers?
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
How to carry out the 4 layer bandaging system (graduated compression)?
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
