Leg Ulcers Flashcards
Causes of leg ulcers?
- Physical (thorns)
- Lymphedema
- Bites
- Infection: bacterial/fungal/protozoa
- Pyoderma gangrenosum
- Necrobiosis lipoidica
- Haematologic diseases (sickle cell)
- Vasculitis
- Vasculopathies
- Neoplasms
- Hypercoagulable states
- Vaso-occlusion
- Systemic sclerosis
- Panniculitis
- Vascular proliferation
- Drugs
- Metabolic
- Genetic
- common to rare
Classification of causes of leg ulcers?
- venous
- arterial
- neuropathic
Risk factors of venous ulcers?
- Obesity
- Pregnancy
- Prolonged standing
- Age
- Family history
Venous flow mechansims?
- venous valve
- skeletal muscular pump
Pathogenesis of venous insufficiency?
- Venous pressure↑ →capillary pressure↑ → capillaries dilate →gaps between endothelial cells →leakage of fluid, proteins, leucocytes, red blood cells, fibrine
- Capillaries irritated →thrombocytes stick to the vessel wall →microthrombi
Clinical signs of venous insufficiency?
- Venulectasias medial side foot
- Varicose veins
- Pitting edema
- Brown discoloration ←haemosiderin deposition ←red blood cells extravasation
- Stasis dermatitis
- Lipodermatosclerosis
- Atrofie blanche
- Leg ulcer (above medial malleolus)
What is venulectasias?
a small dilated, subdermal vein, blue to green in color with a diameter >1mm and <3mm which often develops in the lower extremities due to venous insufficiency
aka reticular veins
What are varicose veins?
a dilated often tortuous, subcutaneous vein with a diameter >3mm which can develop in the lower extremities due to venous insufficiency
What is pitting edema?
pressing the affected area displaces fluid, leaving a finger shaped depression/pit that disappears within seconds
What is non-pitting edema?
not compressible - caused by chronic lymphedema or myxedema
What is stasis dermatitis?
an inflammatory skin condition characterized by poorly defined erythematous and eczematous patches and plaques on the lower legs caused by edema due to chronic venous insufficiency
Note: may manifest with pruritus and weeping in acute forms and may result in secondary bacterial infections
What is lipodermatosclerosis?
- Localised chronic inflammation→fibrosis of skin and subcutaneous tissue
- Skin indurated, hard, red, hyperpigmented
- Plaque or surrounding entire lower leg
- Inverted champagne bottle shape
What is atrofie blanche?
white, coin- to palm sizedatrophicplaquesdue to absentcapillariesin thefibrotictissue
What is a venous ulcer?
an ulceration of the skin caused by chronic venous insufficiency
- classically develops superior to the medial malleolus (ankle)
- often associated with skin changes like hyperpigmentation, and unilateral edema
- is usually nos so deep and has an irregular border
Unconventional treatment of venous ulcers?
- maggots
- leeches
Treatment of venous ulcers?
- Compression
- Moist environment
- Occlusion
- Honey
- Ointment - Skin grafting
- Full thickness
- Split skin graft
- Punch grafts
Describe the smells that accompany certain bacterial wound infections?
- staph aureus - bit yeasty
- pseudomonas - sweet grape, omelette
- E. coli - light diarrhea, vomit, bit sweet
Treatment of wound infections?
- Staph aureus
- Topical antibiotic, antiseptic (povidon-iodine).
- Flucloxacillin, Amoxicillin/clavulanic acid - Pseudomonas
- Acetic acid 1-3% gauzes bd - E. coli
- Topical
Causes of arterial leg ulcers?
- Atherosclerosis
- Martorell hypertensive ulcer
- AV malformation
- Cholesterol embolism
Pathogenesis of arterial ulcers?
Atherosclerosis → blood perfusion↓ →Pain + Tissue necrosis & ulceration
Risk factors for arterial ulcers?
- Cigarette smoking
- Diabetes mellitus
- Hypertension
- Hypercholesterolaemia
Clinical signs of arterial ulcers?
- Leg pain by walking; relief by resting.
- Leg pain at elevation
- Cold feet
- Absent arterial pulses
- Capillairy refill absent/sluggish
- Ulcer round, deep, sharply demarcated, fibrous base
Treatment of arterial ulcers?
- Compression
- Moist environment
- Skin grafting
- As other ulcers - Pain reduction
- Stop atherosclerosis progression:
-exercise; -lifestyle change - Arterial dilation: nifedipine
- Anticoagulant
What is atherosclerosis?
The formation of lipid, cholesterol, and/or calcium-laden plaques within the tunica intima of the arterial wall, which can restrict blood flow
Note: Rupture can cause intraluminal thrombosis that results in myocardial infarction, unstable angina, and/or ischemic stroke
What is Martorell hypertensive ulcer?
Martorell hypertensive ulcer, also known as hypertensive ischemic leg ulcer or painful purpuric ulcer, is a skin complication associated with chronic hypertension. It typically presents as a painful, non-healing ulcer on the lower extremities, especially the pretibial region
Causes of Martorell hypertensive ulcer?
The primary cause of Martorell hypertensive ulcer is chronic hypertension, which leads to vascular changes and reduced blood flow to the affected skin. The condition is often associated with long-standing, poorly controlled hypertension
Factors that contribute to the development of the Martorell ulcer?
- Arteriosclerosis: Chronic hypertension can lead to arteriosclerosis, a condition characterized by thickening and hardening of the arterial walls, reducing blood supply to tissues.
- Ischemia: Reduced blood flow results in tissue ischemia, particularly in the pretibial area, leading to the formation of painful ulcers.
- Secondary Factors: Other factors, such as diabetes mellitus or smoking, can exacerbate vascular complications and contribute to the development of Martorell hypertensive ulcer.
Clinical features of Martorell hypertensive ulcer?
- Location - Typically affects the lower extremities, especially the pretibial region.
- Appearance - Painful purpuric lesions progress to ulcers with irregular borders.
- Pain - Patients often experience severe pain at the ulcer site.
- Chronicity - The ulcers are chronic and may be resistant to healing.
General management of martorell hypertnsive ulcer?
Early recognition and effective management of Martorell hypertensive ulcer, coupled with optimal blood pressure control, are essential to improve outcomes and prevent complications.
Treatment of martorell hypertensive ulcer?
- Blood Pressure Control - The cornerstone of treatment involves achieving and maintaining optimal blood pressure control. Antihypertensive medications may be prescribed to manage hypertension effectively.
- Wound Care - Local wound care is essential to prevent infection and promote healing. This may include cleaning the ulcer, applying dressings, and offloading pressure from the affected area.
- Topical Therapies - Topical treatments, such as wound-healing ointments or dressings, may be used to facilitate the healing process.
- Pain Management - Pain control is crucial, and analgesics may be prescribed to alleviate the severe pain associated with Martorell hypertensive ulcer.
- Vascular Assessment - Evaluation of vascular status through imaging studies may be performed to assess blood flow and identify any underlying vascular issues that need to be addressed.
- Lifestyle Modifications - Patients are often advised to make lifestyle changes, including smoking cessation, maintaining a healthy diet, and regular exercise.
- Multidisciplinary Approach - Collaboration with specialists such as vascular surgeons, wound care specialists, and dermatologists may be necessary for comprehensive management
Causes of neuropathic leg ulcers?
- leprosy
- diabetes mellitus
Types of Neuropathic ulcers?
- Sensory neuropathy: loss of
sensation →trauma - Motor neuropathy: muscle atrophy
→ deformities →joints: Charcot foot - Autonomic neuropathy:
- loss of sweating →dry skin →fissures →bacterial entry →infections
- blood flow regulation↓ →cutaneous perfusion↓ →ulceration
Treatment of neuropathic ulcer?
- Eradication infection
- Prevention trauma - inspection, care, therapeutic shoes
- Wound cleansing, debridement, incl callus
- Moist wound healing, beware of maceration
What is pyoderma gangrenosum?
A neutrophilic dermatosis that manifests with painful, rapidly progressive, erythematous papules and/or pustules that can develop into deep, ulcerated lesions with central necrosis. Associated with inflammatory bowel diseases and autoimmune and hematologic disorders.
How does pyoderma gangrenosum start?
nodule, after skin injury (prick, bite)
What does pyoderma gangrenosum look like?
- irregular ulcer (moth eaten)
- raised, dark-red-purple inflammatory border
- undermined
-halo of erythema
-Base: necrotic
Course of pyoderma gangrenosum?
unpredictable, Weeks-months, Slow or rapid
Association of pyoderma gangrenosum?
colitis ulcerosa, Crohn, Rheumatoid Arthritis, (SLE, Behçet, e.o.)
Treatment of pyoderma gangrenosum?
immunosuppressants(e.g.,corticosteroids,cyclosporine A)
topical and systemic (prednisone)
