Ulcers

Question 1

What is the cause of venous leg ulcers?

Answer 1

Venous HTN, secondary to chronic venous insufficiency (most commonly)
Other causes inc. calf pump dysfunction or neuromuscular disorders

Question 2

Where are venous ulcers usually found?

Answer 2

Lower 3rd of leg (gaiter area)
Between malleolus + lower calf
Most commonly above medial malleolus

Question 3

Describe the appearance of venous ulcers

Answer 3

Shallow
Irregular borders
Associated skin changes e.g. Haemosiderin deposition, oedema, varicose veins

Question 4

Describe symptoms of venous ulcers

Answer 4

Mild pain, relieved with elevation
Pruritus

Question 5

How should venous ulcers be investigated?

Answer 5

Doppler USS: presence of reflux
Duplex USS: anatomy + flow
ABPI (to r/o arterial/ PAD)
Wound swab + culture: ?infection

Question 6

Describe management of venous ulcers

Answer 6

1st: 4 layer compression stockings
2nd: skin grafting (if not resolved in 12w or area >10cm^2)

Question 7

What causes arterial ulcers?

Answer 7

Peripheral arterial disease

Question 8

List 3 risk factors for arterial ulcers

Answer 8

Smoking
CVD
Diabetes

Question 9

Where are arterial ulcers usually found?

Answer 9

Pressure points
Lateral foot + lateral malleolus
Tips of toes
Bony prominences

Question 10

Describe the appearance of arterial ulcers

Answer 10

Punched out ulcer
Well defined borders
Dry necrotic base
+/- areas of gangrene

Question 11

Describe the symptoms of arterial ulcers

Answer 11

Severe pain
Esp. at night + on elevation

Question 12

What other features of arterial insufficiency may be present with arterial ulcers?

Answer 12

Cool
Reduced pulses
Hair loss
Atrophic skin
Prolonged cap refil time
Low ABPI

Question 13

What investigations are required for arterial ulcers?

Answer 13

Cap refill time (toe)
Buerger test: foot turns pale when elevated then bright red when lowered
ABPI (low)

Question 14

Describe management of arterial ulcers

Answer 14

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

Question 15

What causes neuropathic ulcers?

Answer 15

Peripheral neuropathy
Loss of protective sensation leads to repetitive stress + unnoticed injuries forming
Results in painless ulcers forming on pressure points on the limb.

Question 16

Name 2 causes of peripheral neuropathy that can lead to neuropathic ulcers

Answer 16

Diabetes
B12 deficiency

Question 17

Where do neuropathic ulcers typically appear?

Answer 17

Pressure areas
Plantar surface of metatarsal head Plantar surface of hallux
Heels

Question 18

What condition most commonly leads to limb amputation in diabetics?

Answer 18

Plantar neuropathic ulcer

Question 19

Describe appearance of neuropathic ulcers

Answer 19

Well defined “Punched out”
Variable thickness: severe can involve tendon, bone, fascia

Question 20

Describe symptoms of neuropathic ulcers

Answer 20

Painless
Associated manifestations of neuropathy

Question 21

What is found on examination of neuropathic ulcers?

Answer 21

Glove + stocking distribution of peripheral neuropathy
Warm feet + good pulses (unless concurrent arterial disease)

Question 22

Describe possible manifestations of neuropathy

Answer 22

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)

Question 23

Describe investigations for neuropathic uclers

Answer 23

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)

Question 24

Describe management of neuropathic ulcers

Answer 24

MDT approach
Relieve pressure, turning patients
Optimise glycemic control
Specialised footwear
Wound care dressings +/- debridement

Question 25

What management may be required for refractory neuropathic ulcers?

Answer 25

Negative pressure wound therapy
Hyperbaric O2 therapy
Amputation

Question 26

What is pyoderma gangrenosum?

Answer 26

a neutrophilic dermatosis
presents as rapidly enlarging, very painful ulcer
Idiopathic in 50%

Question 27

Name 3 conditions associated with pyoderma gangrenosum

Answer 27

IBD: UC + Crohns
Rheumatic: RhA + SLE
Haematological: Myeloproliferative disorders

Question 28

Where does pyoderma gangrenosum occur?

Answer 28

Extensor sites of lower limbs
Can occur at stoma sites

Question 29

Describe appearance off pyoderma gangrenosum

Answer 29

Initially small pustule/ red bump/ blood blister
Rapidly progresses
Full-thickness ulcer
Purple/ blue undermined border

Question 30

What is an undermined border?

Answer 30

Loss of underlying support tissue at the border

Question 31

Describe management of pyoderma gangrenosum

Answer 31

Oral steroids
Severe: ciclosporin + infliximab

Question 32

Describe investigations for pyoderma gangrenosum

Answer 32

Characteristic appearance
Pathergy: skin prick test causes a papule, pustule, or ulcer
Swab
+/- biopsy to r/o other causes

Question 33

What are Marjolin ulcers?

Answer 33

malignant transformation of preexisting chronic skin inflammation or scar tissue.
(Squamous cell carcinoma)

Question 34

Where do Marjolin ulcers occur?

Answer 34

At sites of chronic inflammation e.g. burns, osteomyelitis after 10-20y
Mainly on LL

Question 35

Describe appearance of Marjolin ulcers

Answer 35

Nodule with induration
Nonhealing ulcer with rolled edges + granulation tissue

Question 36

Describe investigations for Marjolin ulcers

Answer 36

Punch biopsy
Histology: typically well-differentiated SCC

Question 37

Describe management of Marjolin ulcers

Answer 37

Wide margin excision + skin grafting