Skin ulcers

Question 1

Probability diagnosis

Answer 1

Traumatic ulcer

Decubitus (related to trauma)

Venous insufficiency

Arterial insufficiency

Mixed venous and aterial

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• post-thrombophlebitis
• arterial insufficiency
• skin infarction (thrombolytic ulcer)
• vasculitis:— rheumatoid arthritis, SLE, scleroderma

Infection:

• tropical ulcer
• tuberculosis
• Mycobacterium ulcerans
• postcellulitis
• chronic infected sinus
• AIDS

Malignant:

• squamous cell carcinoma
• Marjolin ulcer (SCC)
• basal cell carcinoma (rodent ulcer)
• malignant melanoma
• ulcerating metastases

Haematological:

• spherocytosis
• sickle cell anaemia

Neurotrophic:

• peripheral neuropathy (e.g. diabetes)
• peripheral nerve injuries (e.g. leprosy)

Other causes:

• pyoderma gangrenosum (diagnosis of exclusion)
• insect and spider bites

Question 3

Masquerades checklist

Answer 3

Anaemia

Diabetes

Drugs (e.g. illicit drugs)

Question 4

Is the patient trying to tell me something?

Answer 4

Consider artefactual ulceration, i.e. factitious.

Question 5

Key history

Answer 5

Helps determine the cause of the ulceration, includes;

• previous DVT or PE
• diabetes
• rheumatoid arthritis
• IBD
• chronic skin ulcers and arterial insufficiency, including a hx of intermittent claudication and ischaemic rest pain.

Drug hx, considering especially;

• beta-blockers and ergotamine; compromise the arterial circulation
• corticosteroids, and NSAIDs; affect healing.

Question 6

Key examination

Answer 6

Any ulcer should be assessed for the following characteristics:

• site
• shape
• siz
• edge
• floor
• base
• discharg
• surrounding skin
• regional lymph nodes

Assess the circulation: venous and arterial

Question 7

Key investigations

Answer 7

according to the clinical findings:

• FBC
• ESR, CRP
• random blood sugar
• rheumatoid factor tests
• duplex Doppler ultrasound
• swab for specific organisms
• biopsy, especially if SCC suspecte

Question 8

Diagnostic tips

Answer 8

The great majority of leg ulcers are vascular in origin due to arterial insufficiency or venous hypertension.

If clinical findings don’t provide the diagnosis, ordering the ankle brachial index (ABI) is essential if pulses are not palpable to exclude arterial disease.

Duplex Doppler ultrasound is the key investigation for venous disease.