Leg Ulcers

Question 1

What does the following image show and what are the features?

Answer 1

Venous Ulcer.
These form due to venous hypertension or chronic insufficiency which results in capillary fibrin cuff or leucocyte sequestration.
Usually located above ankle and is painless. Tend to be shallow and large.

Question 2

What are some features of venous insufficiency?

Answer 2

Occurs due to damage to the valves from age, immobility, obesity, standing or DVT. This causes blood to pool in the veins
Oedema, hemosiderin deposits , lipdermatosclerosis, eczema

Question 3

What are the complications of chronic venous insufficiency?

Answer 3

Cellulitis, poor healing, skin ulcers and pain

Question 4

What is the management of venous ulcers?

Answer 4

• Doppler ultrasound to look for reflux.
• 4 Layer compression banding after exclusion of arterial disease
• If fails to heal after 12 weeks of >10cm then skin grafting

Question 5

What are pressure ulcers?

Answer 5

Occur due to reduced mobility. Prolonged pressure results in reduced blood supply, reduced lymphatic drainage and skin breakdown under pressure.
Use waterlow score.

Question 6

What does the follow image show?

Answer 6

Arterial ulcer. These are small and deep with punched out margin. Associated with other features of PAD (weak distal pulses, skin/hair atrophy)
Typically occurs in toes and heal.
Painful which is worse at night and elevation.
Low ABPI

Question 7

What are neuropathic ulcers?

Answer 7

Occurs at pressure points on feet as patient cannot feel any damage

Question 8

What are the investigations for leg ulcers?

Answer 8

ABPI
Blood tests - lok for infection and co-morbidities
Charcoal swabs - when infection is suspected.

Question 9

What is the management of arterial ulcer?

Answer 9

Same as PAD - statin and clopidogrel and urgent referral to vascular

Question 10

What is the management of venous ulcer?

Answer 10

• Tissue viability clinic,
• Compression therapy (After exclusion of arterial disease via ABPI)
• Pentoxifylline can improve healing but it is not liscenced,
• Antibiotics for any infections
• Analgesia but avoid NSAIDss as these may worsen the condition

Question 11

What is pyoderma gangrenosum?

Answer 11

It is classified as neutrophilic dermatosis (skin condition characterised by dense infiltration of neutrophils in affected area).
It initally presents with small pustule/red bump/blood blister.Later features - skin breaks down in ulcer which often as an edge which is purple. Ulcer can be deep and necrotic.

Question 12

What is a Marjolin’s ulcer?

Answer 12

It is a squamous cell carcinoma which occurs at sites of chronic inflammation after 10-20 years. Mainly occurs on lower limbs