Leg ulcers

Question 1

Arterial ulcers

Answer 1

PAINFUL

Arterial ulcers typically present in elderly men

Location: toes and heel, lateral malleolus, are small and deep, have a ‘punched out’ margin, and do not bleed/ooze.

• Arterial ulcers will typically occur with other features of peripheral arterial disease
• Cold with no palpable pulses
• Low ABPI measurements or doppler
• There may be areas of gangrene

Question 2

Venous ulcers

Answer 2

PAINLESS

Cause: venous hypertension, secondary to chronic venous insufficiency –> capillary fibrin cuff or leucocyte sequestration (other causes include calf pump dysfunction or neuromuscular disorders)

Venous ulcers occur in the gaiter area (above ankle) (more often on the medial side), are large and shallow, have sloping edges, and bleed/ooze.

• typically occur with other features of chronic venous insufficiency (oedema, haemosiderin deposition, lipodermatosclerosis, atrophie blanche etc.)

Deep venous insufficiency is related to previous DVT and superficial venous insufficiency is associated with varicose veins

Doppler ultrasound looks for presence of reflux and duplex ultrasound looks at the anatomy/ flow of the vein

Management: 4 layer compression banding after exclusion of arterial disease (ABPI or doppler) or surgery

If fail to heal after 12 weeks or >10cm2 skin grafting may be needed

Question 3

Neuropathic ulcers

Answer 3

Cause: pressure

Location: Commonly over plantar surface of metatarsal head and plantar surface of hallux

The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients

Management: cushioned shoes to reduce callous formation

Question 4

Pyoderma gangrenosum

Answer 4

Associated with inflammatory bowel disease/RA
Can occur at stoma sites
Erythematous nodules or pustules which ulcerate

Question 5

Marjolin’s ulcer

Answer 5

Squamous cell carcinoma
Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
Mainly occur on the lower limb

excessive granulation tissue, foul-smelling pus, bleed easily on contact

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