Leg ulcers Flashcards
Define what is meant by leg ulcer
Any break in the skin of the lower leg above the ankle present more than 4 weeks
What is the most common type of leg ulcer ?
Venous
Describe the pathogenesis of venous ulcers
Appreciate some of the other causes of leg ulcers
- Arterial leg ulcers – caused by poor blood circulation in the arteries
- Diabetic leg ulcers – caused by the high blood sugar associated with diabetes
- Vasculitic leg ulcers – associated with chronic inflammatory disorders such as rheumatoid arthritis and lupus
- Traumatic leg ulcers – caused by injury to the leg
- Malignant leg ulcers – caused by a tumour of the skin of the leg
When taking a history about a leg ulcer what are some of the key things you should ask about ?
- History – duration of present ulcer. Is this their first ulcer?
- Pain; disturbing sleep; affecting mobility
- Medical history – especially ask about h/o varicose veins, DVT, clotting problems, peripheral vascular disease, arterial disease elsewhere, diabetes.
A history of what conditions if present would suggest a venous cause for a leg ulcer ?
- DVT
- Varicose veins
- Same side fractures/ surgery
A history of what conditions if present would suggest an artieral cause for the leg ulcer?
- PVD
- IHD
- Smoking
- Stroke history
What should all patients with chronic leg ulcers have before treatment is commenced ?
ABPI - ankle brachial pressure index
What does the results of the ABPI mean ?
- 0.8-1.3 normal
- < 0.8 - vascular disease
- >1.5 calcification
What is the recommendation for patients with an ABPI≥0.8?
Compression therapy - 4 layer compression bandaging
What is the recommendation & treatment for patients with a ABPI <0.8? (arterial ulcers)
Patients with an ABPI of <0.8 should be referred for a specialist vascular assessment.
Tx:
- Pain relief
- Lifestyle changes eg smoking
- Aspirin
- Treat infections
- Soffban and crepe bandages toe to knee(reduce oedema)
- Vascular surgery if indicated
During the clinical assessment of leg ulcers what should be measured ?
The surface area of the ulcer should be measured serially over time.
The ulcer edge often gives a good indication of progress and should be carefully documented (eg shallow, epithelialising, punched out).
The base of the ulcer should be described (eg granulating, sloughy).
The position of the ulcer(s), medial, lateral, anterior, posterior, or a combination, should be clearly described.
When should bacterial wound swabs be taken of the leg ulcer ?
Only if there is signs of infection - e.g. If ulcer increasingly painful/exudative/smelly/enlarging
What should patients with a non-healing or atypical leg ulcer be referred for ?
Biopsy - could be due to e.g. malignancy
When should patch testing to previous ulcer treatments eg. Bandages, dressings, creams be done ?
Leg ulcer patients with dermatitis/eczema
When should patients with leg ulcers be referred to the appropriate specialist ?
- Suspicion of malignancy
- Peripheral arterial disease (ABPI <0.8)
- Diabetes mellitus
- Rheumatoid arthritis/vasculitis
- Atypical distribution of ulcers
- Suspected contact dermatitis or dermatitis resistant to topical steroids
- Non-healing ulcer.
Describe how leg ulcers should be cleaned and what may need to be done to clean them
Wash in tap water and dry carefully
Surgical debridement may be necessary
What type of dressings should be used in the treatment of leg ulcers ?
Simple non-adherent dressings
Recap the treatment of venous leg ulcers (ABPI >0.8)
- Control pain
- ABPI
- Non-adherent dressing
- De-sloughing agent if necessary eg hydrogel/ honey
- 4 layer compression bandaging – may need to increase compression gradually if pain a problem
- Leg elevation
Describe the 4 layer bandaging system
- Graduated compression
- 40mmHg at ankle, 25mmHg below knee
- Latex/ rubber free if possible
- Applied by a trained nurse
- Non-adherent dressing
What is the recommened management to help prevent recurrence of venous leg ulcers ?
- Below-knee graduated compression hosiery is recommended to prevent recurrence of venous leg ulcer in patients where leg ulcer healing has been achieved. (compression stockings)
- Patients receive the strongest compression they can tolerate
What is the management of arterial leg ulcers ?
What does the edges of venous leg ulcers tend to look like ?
Tend to have a shallow edge “like a beach”
What are the main signs that an ulcer is venous in origin ?
- Superficial ulceration
- Ulcer present in the gaiter area - “gaiter” area of the leg (i.e. area extending from just above the ankle to below the knee and tends to occur on both lateral and medial aspect of the leg)
- Signs of venous disease - has varicosities (varicose veins) & haemosiderin staining (dark purple or rusty discoloration of the lower legs), varicose eczema, oedema, lipodermatosclerosis, atrophie blanche
What is shown in the pic ?
Haemosiderin staining - sign of venous disease
What is shown in the pic ?
- Lipodermatosclerosis - there is fibrosis & hardening of the skin of the lower leg, which eventually results in narrowing of the distal lower limb creating ‘upside down champagne bottle’ appearance
- It is a sign of venous disease
What is shown in the pic ?
- Atrophe blanche - this is a sign of advanced venous disease
- It is white scar-like areas which indicate ulceration is begining to develop
what type of leg ulcer is shown in this pic ?
Venous leg ulcer
What are the main signs that an ulcer is artieral in origin ?
- Deep punched out
- May exposure underlying structures e.g. tendon
- Location - pressure points/ sites of trauma often e.g. the foot/toes
- Pain esp at night & claudication
- Additionally signs of arterial disease seen - pale, cold limb, absent/ reduced peripheral pulses, delayed CRT, loss of hair
What does the edges of an arterial leg ulcer tend to look like ?
Arterial ulcers may have very sharp, cliff-like edges, and can be described as being “punched out”
What area of the skin do venous leg ulcers tend to develop ?
Normally develop around the malleoli
Where do diabetic and arterial leg ulcers tend to normally develop ?
Often present on the feet, especially around pressure sites such as the heel, or where shoes rub due to neuropathy.
How can skin cancer present which may make you mistake it for a leg ucler ?
Skin cancer can present anywhere on the body, including as a non-healing ulcer on the lower leg.
What is the aim to heal all simple leg ulcers by ?
12 weeks
List the differentials when someone presents with a likely leg ulcer
- Cancer - BCC, SCC
- DVT
- Venous eczema
- Vasculitis
- Psoriasis
- Necrobiosis lipoidia
- Pyoderma gangrenosum
What is shown in this pic ?
A BCC presenting similar to a leg ulcer
What is shown in this pic ?
A SCC presenting similar to a leg ulcer
What features would help distinguish a vasculitis from a leg ulcer ?
- Painful
- Sudden onset
- necrotic
- Purpuric rash
How would you distinguish necroiosis lipoidic from a leg ulcer?
- Mainly appear on the shins of diabetics
- Usually painless patches which are shiny & red/yellow
- Centre of the patch has prominent blood vessels (telangiectasia).
How would you distinguish pyoderma gangrenosum from a leg ulcer ?
- It presents as a rapidly enlarging, very painful ulcer
- It is characterised by a full-thickness ulcer with blue undermined borders and by pathergy (the appearance of new lesions after minor trauma)
How would you distinguish venous eczema from a leg ulcer ?
- They are very itchy, red, scaly plaques
- Collection of fluid in the tissues
- Orange-brown macular pigmentation due to haemosiderin deposition
- ‘Champagne bottle’ shape of the lower leg — narrowing at the ankles and induration (lipodermatosclerosis)
How would you distinguish psoriasis from a leg ulcer ?
- “Burning”
- Leg not hot
- Not itchy
- Also has a rash on his elbows
