Ulcers Flashcards
What is the cause of venous leg ulcers?
Venous HTN, secondary to chronic venous insufficiency (most commonly)
Other causes inc. calf pump dysfunction or neuromuscular disorders
Where are venous ulcers usually found?
Lower 3rd of leg (gaiter area)
Between malleolus + lower calf
Most commonly above medial malleolus
Describe the appearance of venous ulcers
Shallow
Irregular borders
Associated skin changes e.g. Haemosiderin deposition, oedema, varicose veins
Describe symptoms of venous ulcers
Mild pain, relieved with elevation
Pruritus
How should venous ulcers be investigated?
Doppler USS: presence of reflux
Duplex USS: anatomy + flow
ABPI (to r/o arterial/ PAD)
Wound swab + culture: ?infection
Describe management of venous ulcers
1st: 4 layer compression stockings
2nd: skin grafting (if not resolved in 12w or area >10cm^2)
What causes arterial ulcers?
Peripheral arterial disease
List 3 risk factors for arterial ulcers
Smoking
CVD
Diabetes
Where are arterial ulcers usually found?
Pressure points
Lateral foot + lateral malleolus
Tips of toes
Bony prominences
Describe the appearance of arterial ulcers
Punched out ulcer
Well defined borders
Dry necrotic base
+/- areas of gangrene
Describe the symptoms of arterial ulcers
Severe pain
Esp. at night + on elevation
What other features of arterial insufficiency may be present with arterial ulcers?
Cool
Reduced pulses
Hair loss
Atrophic skin
Prolonged cap refil time
Low ABPI
What investigations are required for arterial ulcers?
Cap refill time (toe)
Buerger test: foot turns pale when elevated then bright red when lowered
ABPI (low)
Describe management of arterial ulcers
Mx of arterial disease
Lifestyle: smoking cessation, WL
Medical: statins, anti platelet, optimisation of BP + glucose
Wound care +/- Tx of infection
Surgical: angioplasty or bypass grafting. Skin grafting for non-healing ulcers despite good blood supply
What causes neuropathic ulcers?
Peripheral neuropathy
Loss of protective sensation leads to repetitive stress + unnoticed injuries forming
Results in painless ulcers forming on pressure points on the limb.
Name 2 causes of peripheral neuropathy that can lead to neuropathic ulcers
Diabetes
B12 deficiency
Where do neuropathic ulcers typically appear?
Pressure areas
Plantar surface of metatarsal head Plantar surface of hallux
Heels
What condition most commonly leads to limb amputation in diabetics?
Plantar neuropathic ulcer
Describe appearance of neuropathic ulcers
Well defined “Punched out”
Variable thickness: severe can involve tendon, bone, fascia
Describe symptoms of neuropathic ulcers
Painless
Associated manifestations of neuropathy
What is found on examination of neuropathic ulcers?
Glove + stocking distribution of peripheral neuropathy
Warm feet + good pulses (unless concurrent arterial disease)
Describe possible manifestations of neuropathy
Burning/ tingling in legs (painful neuropathy)
Single nerve involvement (mononeuritis multiplex, such as CN III or median nerve)
Amotrophic neuropathy (painful wasting of proximal quadriceps)
Describe investigations for neuropathic uclers
Blood glucose (random or HbA1c)
Vit B12
ABPI +/- duplex: ? concurrent arterial disease
Assess extent of peripheral neuropathy with monofilament
Swab: ?infection
XR: ?osteomyelitis (if signs of deep infection)
Describe management of neuropathic ulcers
MDT approach
Relieve pressure, turning patients
Optimise glycemic control
Specialised footwear
Wound care dressings +/- debridement
What management may be required for refractory neuropathic ulcers?
Negative pressure wound therapy
Hyperbaric O2 therapy
Amputation
What is pyoderma gangrenosum?
a neutrophilic dermatosis
presents as rapidly enlarging, very painful ulcer
Idiopathic in 50%
Name 3 conditions associated with pyoderma gangrenosum
IBD: UC + Crohns
Rheumatic: RhA + SLE
Haematological: Myeloproliferative disorders
Where does pyoderma gangrenosum occur?
Extensor sites of lower limbs
Can occur at stoma sites
Describe appearance off pyoderma gangrenosum
Initially small pustule/ red bump/ blood blister
Rapidly progresses
Full-thickness ulcer
Purple/ blue undermined border
What is an undermined border?
Loss of underlying support tissue at the border
Describe management of pyoderma gangrenosum
Oral steroids
Severe: ciclosporin + infliximab
Describe investigations for pyoderma gangrenosum
Characteristic appearance
Pathergy: skin prick test causes a papule, pustule, or ulcer
Swab
+/- biopsy to r/o other causes
What are Marjolin ulcers?
malignant transformation of preexisting chronic skin inflammation or scar tissue.
(Squamous cell carcinoma)
Where do Marjolin ulcers occur?
At sites of chronic inflammation e.g. burns, osteomyelitis after 10-20y
Mainly on LL
Describe appearance of Marjolin ulcers
Nodule with induration
Nonhealing ulcer with rolled edges + granulation tissue
Describe investigations for Marjolin ulcers
Punch biopsy
Histology: typically well-differentiated SCC
Describe management of Marjolin ulcers
Wide margin excision + skin grafting
