Leg Ulcers

Question 1

What is a leg ulcer

Answer 1

a break in the skin, usually with full epidermal loss, potentially dermal loss too

Question 2

what are common causes of leg ulceration

Answer 2

venous disease (70%)
arterial disease (6%)
neuropathy
pressure

Question 3

what are rarer causes of leg ulceration

Answer 3

pyoderma gangrenosum
vasculitits
polyarteritis nodosa
SCC

Question 4

how should you investigate a leg ulceration

Answer 4

?infection - CRP/ESR, FBC
?Diabetes - fasting glucose + urinalysis
?vasculitis - autoantibody screen, U+E, LFT
?inflammatory/neoplastic - biopsy ulcer margin

Question 5

whats the pathology of venous ulcers

Answer 5

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

Question 6

what are common causes of VENOUS leg ulcers

Answer 6

neuromuscular dysfunction

damage from DVT

Question 7

what are the common symptoms of venous disease

Answer 7

leg heaviness
swelling 
ankle swelling 
varicose veins 
haemosedrin deposition 
lipodermatosclerosis  (wine bottle leg) 
atrophie blanc (white deposits in leg)

Question 8

how can you differentiate venous ulcers from other ulcers

Answer 8

venous ones tend to be big, shallow with less defined borders and increased skin changes (haemosedrin deposition, lipodermatosclerosis and atrophie blanc)

Question 9

what is haemosedrin deposition

Answer 9

red/brown discolouration in the leg

Question 10

what is lipodermatosclerosis

Answer 10

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

Question 11

what is atrophie blanc

Answer 11

smooth white atrophic plaques, usually on the medial malleolus

Question 12

what are common complications of venous ulcers + what are the treatments

Answer 12

superficial infection - topical antiseptic
cellulitis - systemic Abx (penecillins)
lymphedema - compression

Question 13

whats the pathology of arterial ulcers

Answer 13

atheromas (usually) leading to ischaemia, ulceration and necrosis

other causes outside of atheroma are: 
emboli
vasospastic disease
trauma
circulatory collapse

Question 14

how can you differentiate arterial ulcers from other ulcers

Answer 14

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

Question 15

what is the most likely ulcer pathology if you can see sub dermal structures (muscle/bone)

Answer 15

arterial

Question 16

what is the treatment for arterial ulcers

Answer 16

revascularisation - refer to vascular surgeons

Question 17

what is the pathology of neuropathic ulcers

Answer 17

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

Question 18

what is the most common area for neuropathic ulcers

Answer 18

below the metatarsal heads

Question 19

what are some symptoms of peripheral neuropathy associated with neuropathic ulcers

Answer 19

burning sensation
shooting pain
altered pain sensation (allodynia/hyperalgesia)
paraesthesia

Question 20

how do you differentiate a neuropathic ulcers from the other ones

Answer 20

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

Question 21

whats the treatment for neuropathic ulcers

Answer 21

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

Question 22

how do you manage venous ulcers

Answer 22

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

Question 23

what should be done before applying compression on a venous ulcer

Answer 23

checking it is definitely not an arterial ulcer (as pressure would make these worse) by doing an ABPI

ABPI <0.8 = arterial disease

Question 24

why should antiseptic be avoided in venous ulcers

Answer 24

washes out and kills granulation tissue which is required for healing

Question 25

what is done for the skin changes in venous ulceration

Answer 25

steroid cream and emmolients