Leg Ulcers Flashcards
What is a leg ulcer
a break in the skin, usually with full epidermal loss, potentially dermal loss too
what are common causes of leg ulceration
venous disease (70%)
arterial disease (6%)
neuropathy
pressure
what are rarer causes of leg ulceration
pyoderma gangrenosum
vasculitits
polyarteritis nodosa
SCC
how should you investigate a leg ulceration
?infection - CRP/ESR, FBC
?Diabetes - fasting glucose + urinalysis
?vasculitis - autoantibody screen, U+E, LFT
?inflammatory/neoplastic - biopsy ulcer margin
whats the pathology of venous ulcers
usually secondary to a failure of the calf muscle to pump blood back up, or a valve failure which leads to reflux, stasis and a release of toxic mediators causing ischaemia/inflammation - although this mechanism isnt fully understood
what are common causes of VENOUS leg ulcers
neuromuscular dysfunction
damage from DVT
what are the common symptoms of venous disease
leg heaviness swelling ankle swelling varicose veins haemosedrin deposition lipodermatosclerosis (wine bottle leg) atrophie blanc (white deposits in leg)
how can you differentiate venous ulcers from other ulcers
venous ones tend to be big, shallow with less defined borders and increased skin changes (haemosedrin deposition, lipodermatosclerosis and atrophie blanc)
what is haemosedrin deposition
red/brown discolouration in the leg
what is lipodermatosclerosis
inflammation of subcutaneous fat which gets lost, resulting in pain/swelling, hardening and induration of the skin and a tapering of the lower part of the leg so it looks like an upside-down wine bottle
what is atrophie blanc
smooth white atrophic plaques, usually on the medial malleolus
what are common complications of venous ulcers + what are the treatments
superficial infection - topical antiseptic
cellulitis - systemic Abx (penecillins)
lymphedema - compression
whats the pathology of arterial ulcers
atheromas (usually) leading to ischaemia, ulceration and necrosis
other causes outside of atheroma are: emboli vasospastic disease trauma circulatory collapse
how can you differentiate arterial ulcers from other ulcers
they are well demarcated deep ulcers that are characteristically quite painful
no skin discolouration, instead skin is smooth, hairless and shiny
the base also has little granulation tissue and almost appears dry
what is the most likely ulcer pathology if you can see sub dermal structures (muscle/bone)
arterial
what is the treatment for arterial ulcers
revascularisation - refer to vascular surgeons
what is the pathology of neuropathic ulcers
combined loss of sensation in certain areas and atrophy of certain muscles and fat deposits leading to increased pressure distribution in certain areas of the foot, causign increased ulcer risk due to the bony prominences in the foot. combined with the lack of sensation in the foot ulcers can develop easily
what is the most common area for neuropathic ulcers
below the metatarsal heads
what are some symptoms of peripheral neuropathy associated with neuropathic ulcers
burning sensation
shooting pain
altered pain sensation (allodynia/hyperalgesia)
paraesthesia
how do you differentiate a neuropathic ulcers from the other ones
they tend to be well-demarcated ‘punch-outs’ that are completely painless, with a thick yellow calous rim around the base
there tends to be no skin changes
whats the treatment for neuropathic ulcers
treat any co-existing arterial disease/reversible neuropathic issues, provide orthotic devices to change the pressure distribution in the foot to prevent further ulceration
debridement of the ulcer may promote healing
how do you manage venous ulcers
4 layer dressings applying roughly 40mmHg pressure for 2-7 days followed by lifelong compression hoisery (e.g stockings that have 35mmHg pressure
identifying and treating complications
skin grafts sometimes required
what should be done before applying compression on a venous ulcer
checking it is definitely not an arterial ulcer (as pressure would make these worse) by doing an ABPI
ABPI <0.8 = arterial disease
why should antiseptic be avoided in venous ulcers
washes out and kills granulation tissue which is required for healing
what is done for the skin changes in venous ulceration
steroid cream and emmolients
