Stasis And Leg Ulcers

Question 1

Stasis dermatitis: presentation

Answer 1

erythema, scale, pruritis, erosions, exudate & crust

• (U) located on the lower 1/3 of the legs, superior to the medial malleolus
• can occur bilaterally or unilaterally
• lichenification may develop
• edema often present, varicose veins & hemosiderin deposits (pinpoint yellow-brown macules)

Question 2

Stasis dermatitis is a cutaneous marker of what?

Answer 2

venous insufficiency

Question 3

How does venous stasis occur

Answer 3

valves in the deep or perforating veins become incompetent causing reflux into the superficial system (venous hypertension_

Question 4

normal venous return occurs how

Answer 4

venous blood returns from the superficial venous system via perforating veins into the deep venous system

Question 5

Risk factors for venous insufficiency (7)

Answer 5

1. heredity
2. age (older)
3. female
4. pregnancy
5. obesity
6. prolonged standing
7. greater height

Question 6

chronic venous dz:
prevalence
quality of life

Answer 6

extremely common

a/w reduced quality of life secondary to pain, decreased physical function & mobility

Question 7

Early signs of venous insufficiency (5)

Answer 7

1. tenderness
2. edema
3. hyperpigmentation
4. telangiectasis
5. varicose veins

Question 8

Late signs of venous insufficiency (3)

Answer 8

1. Lipodermatosclerosis (subQ fat is replaced by fibrosis->eventually impedes venous & lymph flow->edema above fibrosis)
2. venous ulcers
3. Scars that appear porcelain white & atrophic

Question 9

Lipodermatosclerosis

Answer 9

stasis dermatitis->fat necrosis w/end stage being permanent sclerosis (lipodermatosclerosis) w/ “inverted champagne bottle” legs

Question 10

pts with lipodermatosclerosis may also have

Answer 10

acute inflammatory episodes that present w/pain & erythema (these episodes can be mistaken for cellulitis)

Question 11

Elaphantiasis Verrucosa Nostra

Answer 11

inflammation of the draining lymphatics (as occurs w/cellulitis) results in damage to those vessels resulting in lymphatic insufficiency

• overlying skin becomes pebbly, hyperkeratotic & rough
• ulceration in this setting (w/lymphatic & venous insufficiency) is significantly harder to tx & heal

Question 12

Complications of Venous Insufficiency (4)

Answer 12

1. recurrent ulcers
2. cellulitis (open wound provides a portal of entry for bacteria)
3. contact dermatitis (from topical agents applied to stasis dermatitis or ulceration)
4. venous thrombosis

Question 13

Relationship btwn Leg Ulcers & Contact Dermatitis

Answer 13

-leg ulcers can become sensitized to products used to tx wound healing->leads to contact dermatitis

(due to intrinsic allergenic props of many ointments & wound props, duration of use & disrupted skin barrier)

the chronic inflammation + resultant dermatitis ->poor wound healing &/or recurrent ulcers

Question 14

Stasis dermatitis: treatment

Answer 14

imp to tx both dermatitis & underlying venous insufficienct

1. apply super-high & high potency steroids to area of dermatitis
2. elevation (to reduce edema)
3. compression therapy with leg wraps
4. change wraps weekly, or more often if lesion is very weepy

Question 15

active or healed venous leg ulcers: prevalence

Answer 15

1% of the general population

Question 16

Venous Insufficiency Ulcers: presentation, sxs, location

Answer 16

tender, shallow, irregular ulcers w/a fibrinous base

sxs: aching or pain, discomfort may be relieved by elevation

ALWAYS LOCATED BELOW THE KNEE- (U) on medial ankle or along the line of long or short saphenous veins
-accompanied w/leg edema, hemosiderin pigmentation, +/-leg dermatitis

Question 17

Leg ulcers:

causes (5) & prevalence

Answer 17

1. venous insufficiency (45-50%)
2. arterial insufficiency (10-20%)
3. Combo of venous and arterial (10-15%)
4. Diabetic (15-25%)
5. malignancy, vasculitis, collagen-vascular dz, & dermal manifestations of systemic dz may present as ulcers on LE

Question 18

2 things that increase risk for ulcer development & persistence (independent of underlying cause)

Answer 18

smoking

obesity

Question 19

ABI: definition
normal
abnormal means?

Answer 19

Ankle/Brachial Index

ratio of systolic BP in ankle to systolic BP in brachial artery

normal=0.8 or more

<0.8=indication of peripheral artery dz

Question 20

Why do we measure ABI?

Answer 20

to exclude arterial occlusive dz

-compression therapy (used to tx venous insufficiency) is contraindicated in pts w/significant arterial dz

Question 21

ABI: reliability

Answer 21

reliable except in diabetes (may be falsely high)

Question 22

ABI should be performed in which pts?

Answer 22

all pts w/weak peripheral pulses, risk factors for arterial occlusive dz (smoking, diabetes, hyperlipidemia) & when ulcers are in locations not consistent w/venous ulcers

Question 23

Venous ulcers: physical exam should include (in addition to assessment of ulcer)

Answer 23

eval of peripheral pulses, capillary refill time, peripheral neuropathy, and deep tendon reflexes

Question 24

Dx of venous leg ulcers

Answer 24

can be made clinically

but
non-invasive studies (venous duplex ultrasound & venous rheography) can help document the presence & etiology of venous insufficiency
-findings may warrant surgical intervention w/venous laser ablation to prevent further complications
-surgical intervention is (U) more helpful when venous dz is limited

Question 25

Venous Ulcers: Treatment

Answer 25

address the underlying cause (venous insufficiency) as well as local wound care: - leg elevation - keep wound moist w/a primary dressing - tx dermatitis w/topical steroids - compression theory (except w/an ABI <0.8) - tx infection w/debridement of necrotic or infected tissues & use systemic Abx for infection - measure the ulcer at each visit to document improvement

Question 26

Wound care: the primary dressing (3 main points)

Answer 26

1. keep the wound moist (moist environ promotes healing compared to air exposure) 2. choice of dressings less imp than the program of ulcer tx outlined on the previous slid 3. semipermeable dressings that allow oxygen & moisture to pass through (but not water) have made the tx of leg ulcers easier & more effective

Question 27

Venous Ulcers: patient education (4)

Answer 27

1. AVOID TOPICAL ABX in order to prevent sensitization & development of contact dermatitis 2. cleanse wound with saline, avoid products like betadine & hydrogen peroxide to avoid skin breakdown 3. AVOID frequent MANIPULATION OF WOUND. Dressings can be changed as infrequently as once weekly. 4. once healed, use 20-30mmHg compression stockings (to avoid reaccumulation & development of ulcers)

Question 28

Venous Ulcer: when to refer & who to refer to

Answer 28

when venous ulcers do not demonstrate response to tx (reduction in size) after 6 weeks, refer to dermatology or wound care clinic

Question 29

Arterial ulcers: | cause

Answer 29

peripheral artery dz

Question 30

Arterial ulcers: location

Answer 30

occurs on lower leg, (U) over sites of pressure & trauma: pretibial, supramalleolar & at distant points such as toes & heels

Question 31

Arterial ulcers: presentation

Answer 31

lower leg appear "punched out" w/well-demarcated edges & a pale base - exudation is minimal - associated findings of ischemia: loss of hair on feet & lower legs, shiny atrophic skin

Question 32

Arterial Ulcers: other physical exam/history findings

Answer 32

Pulses (dorsalis pedis & posterior tibial) may be diminished or absent Stasis pigmentation & lipodermatosclerosis are absent (unless pt also has venous dz) a/w intermittent claudication & pain: as dz progresses, pain & claudication may occur at rest, LEG PAIN (U) DOESN'T DIMINISH WHEN THE LEG IS ELEVATED (unlike venous ulcers)

Question 33

Which recommendation should take priority in a patient with an arterial ulcer?

Answer 33

Refer to a vascular surgeon | main goal of tx is to re-establish adequate arterial supply

Question 34

Arterial ulcers: treatment (4)

Answer 34

1. refer to a vascular surgeon for restoration of arterial blood flow w/percutaneous or surgical arterial reconstruction 2. Stop smoking, optimize control of diabetes, HTN & hyperlipidemia 3. Weight loss & exercise help 4. all ulcers require proper wound care

Question 35

Diabetic (Neuropathic) foot ulcers: what 3 things play prominent roles in their developement

Answer 35

peripheral neuropathy pressure trauma

Question 36

Diabetic (neuropathic) foot ulcers: usual locations? how do they develop?

Answer 36

(U) located on plantar surface under metatarsal heads or on toes repetitive mechanical forces lead to CALLUS, the most imp preulcerative lesion in neuropathic foot

Question 37

what is the most important preulcerative lesion in the neuropathic foot

Answer 37

CALLUS

Question 38

Diabetics: lifetime risk of developing a foot ulcer

Answer 38

25%

Question 39

Risk factors for foot ulcers (8)

Answer 39

1. cigarette smoking 2. past foot ulcer hx 3. peripheral vascular dz 4. previous amputation 5. poor glycemic control 6. peripheral neuropathy 7. diabetic nephropathy 8. visual impairment

Question 40

diabetic pts w/foot ulcers best managed where

Answer 40

in a multidisciplinary setting (podiatrists, endocrinologists, dietician)

Question 41

Evaluation of Diabetic Foot Ulcer

Answer 41

Remove callous surrounding the ulcer (with slogh & nonviable tissue) Probe ulcer to reveal sinus extending to bone or undermining edges where probe can be passed from ulcer underneath surrounding intact skin - if suspected bone involvement, order imaging study - if suspected osteomyelitis, admit to hospital for evaluation & tx

Question 42

Diabetic foor ulcer: tx

Answer 42

use dressing to maintain a moist environment apply platelet-derived growth factor gel (shown to improve wound healing in diabetic foot ulcers) protect the ulcer from excessive pressure - redistribute plantar pressures w/casting or special shoes - restrict weight bearing of involved extremity

Question 43

Diabetic foot ulcers: prevention (6)

Answer 43

1. glycemic control 2. annual foot exams w/clinical assessment for peripheral vascular dz & monofilament test for peripheral neuropathy 3. pts should examine own feet regularly 4. if present, tx tinea pedis (to prevent associated skin barrier disruption) 5. encourage smoking cessation (risk factor for vascular dz & neuropathy) 6. optimize tx of HTN, hyperlipidemia & obesity

Question 44

Pyoderma Gangrenosum: what is it? how does it present?

Answer 44

inflammatory ulcerative process mediated by influx of neutrophils into the dermis begins as small pustule->breaks down & rapidly expands forming an ulcer w/an undermined violaceous border satellite ulcerations may merge w/central larger ulcer - rapid progression (days to weeks) - can occur anywhere on body, most often on LEs - can be VERY PAINFUL

Question 45

Pyoderma Gangrenosum: cause

Answer 45

triggered by trauma (pathergy), including insect bites, surgical debridement, attempts to graft

Question 46

Pyoderma Gangrenosum is often misdiagnosed as

Answer 46

brown recluse spider bite

Question 47

Pyoderma Gangrenosum: underlying conditions associated pathologies

Answer 47

majority of pts do not have an underlying condition BUT often a/w a wide range of other pathologies the pt should be evaluated for: IBD (1.5-5% of pts get PG), rheumatoid arthritis, hematologic dyscrasias, malignancy 1/3 of PG patients have arthritis: seronegative, asymmetric, monoarticular, large joint

Question 48

Pyoderma Gangrenosum: tx

Answer 48

a dermatologic emergency, consider URGENT REFERRAL to dermatologist tx of underlying dz doesn't (U) help PG topical therapy: superpotent steroids, topical tacrolimus systemic therapy: systemic steroids, cyclosporine, tacrolimus, cellcept, thalidomide, TNF-inhibitors

Question 49

Pyoderma Gangrenosum: dx

Answer 49

dx of exclusion; no specific histological or clinical features skin biopsy often performed to exclude other conditions (but this is not diagnostic)