Ulcers

Question 1

What is the usual location for venous ulcers?

Answer 1

Medial malleolus

Question 2

Why is the medial malleolus the most common location for venous ulcers?

Answer 2

Cockett’s perforating veins in that area

Question 3

What physical exam findings should be documented in an ulcer?

Answer 3

Location, size, depth, description of the base (yellow, fibrinous, purulent, eschar, etc), the surrounding sidewalls (rolled, indurated, undermined, color), and the surrounding skin (erythema, color change, livido, puprua, stasis changes? etc)

Question 4

What physical exam findings might tip you off that an ulcer is from venous origin?

Answer 4

Look for a background of venous stasis (brown hemosiderin deposits, pinpoint purpura, edema lipodermatosclerosis, and varicosities.

Question 5

What is the common appearance of a venous ulcer?

Answer 5

Tend to occur on the medial malleolus and tend to have irregular borders and yellow fibrinous base. Though these can be big they tend to be shallow w/ granulation tissue evident after debridement.

Question 6

What is the treatment for a venous ulcers?

Answer 6

Wound care that promotes moist wound bed/occlusion, the elevation of the legs, compression.

NOTE before doing compression therapy coexistent arterial insufficiency and or heart failure need to be exluded

Question 7

When should patients be counseled to apply stockings for compression in the setting of venous ulcers of edema?

Answer 7

In the morning, before even getting out of bed if possible as legs will be at their smallest size

Question 8

What level of compression at the ankle is needed for edema in aiding in the healing of venous ulcers?

Answer 8

30-40mmHg at the ankle

Question 9

What is elephantiasis nostras verrucosa?

Answer 9

Chronic lymphedema of the feet/legs that leads to fibrosis of the dermis and subcutis leading to verrucous, hyperkeratosis, cobblestone-like lesions w/ a papillomatous appearance

Question 10

What are 3 causes of primary lymphedema?

Answer 10

Nonne-Milroy dz, Meige dz, lymphedema tarda

Question 11

How do you distinguish between Nonne-Milroy dz, Meige dz, lymphedema tarda?

Answer 11

Milroy= unilateral lower extremity lymphedema +/- hydrocele. Due to mutations in VEGFR-3/FLT4 (AD). Onset is early

Meige disease: AD, FOXC2 gene, most common form of primary lymphedema, usually causes lymphedema of the legs but other areas can occur. Unlike Milroy’s this one usually starts at puberty

Lymphedema tarda: Presents after age 35, usually 2/2 to developmental abnormality being preciptated by some insult

Question 12

What are some secondary causes of lymphedema that could lead to ulcer?

Answer 12

Lymph node dissection, recurrent cellulitis, obesity, filariasis

Question 13

What are some risk factors for arterial ulcer?

Answer 13

Tobacco use, DM2, HTN, hyperhomocysteinemia, HLD

Question 14

What is the presentation of arterial ulcer?

Answer 14

Painful ulcer w/ well-defined borders with round punched out, dry, necrotic base

Question 15

What is the classical location for ulcer?

Answer 15

Lateral malleolus as well as first and with metatarsal heads

Question 16

What clues in the surrounding skin may tip you off to arterial ulcer?

Answer 16

Atrophic skin, no hair

Question 17

How are arterial ulcers diagnosed?

Answer 17

ABI’s are key in dx, but can consider other vascular imaging such as CTA, MRA, or angiography

Question 18

What treatments must be avoided in ulcer?

Answer 18

Must avoid sharp debridement or vac treatments

Question 19

What are some physical exam findings which may lead you to suspect arterial ulcer?

Answer 19

Cool extremities, weak or absent pulses, prolonged capillary refill time, pallor or pain with leg elevation (left to 45 degrees for 1 minute), and dependent rubor after lowering.

Question 20

What should be considered if a violaceous plaque in an area of vascular change (large breasts, lower legs, etc)

Answer 20

Think about diffuse dermal angiomatosis

Question 21

What should be considered if one sees a violaceous plaque on the lower medial extremity that looks like KS?

Answer 21

Should also think about acroangiodermatitis (pseudo-Kaposi’s sarcoma).

Question 22

What is the classic presentation of diabetic/neuropathic ulcers?

Answer 22

These often have a moist base with a punched out base and callused borders

Question 23

What are the most common locations of diabetic/neuropathic ulcers?

Answer 23

Pressure points (metatarsal heads, great toes, heels)

Question 24

What is the mechanism of diabetic or neuropathic ulcers?

Answer 24

Neuropathy leads to unrecognized foot trauma and motor neuropathy leads to altered biomechanics and structural deformities, and autonomic abnormalities lead to arterio-venous shunting and then that decreases perfusion and reduces sweating all of which leads to dryness, injury, and fissuring

Question 25

What important condition should be ruled out with a diabetic ulcer and how can it be assessed?

Answer 25

Osteomyelitis can occur in the setting of ulcers and should be r/o with MRI ideally. If suspected, antibx should be held until bone bx can be done ideally

Question 26

Treatments for diabetic ulcers?

Answer 26

Off-loading measures are the mainstay (shoes, etc), debridement, treatment of infection, negative pressure therapy, etc

Question 27

What are the 4 stages of decubitus ulcers?

Answer 27

1. Non-blanchable erythema with induration and warmth 2. Irregular shallow ulceration; loss of epidermis, dermis or both with erythema, induration and warmth 3. Deep ulceration with decrotitic base 4. Deep ulceration reaching the underlying bone ## Footnote If bottom not visualized or eschar is covering ulcer may be unstageable

Question 28

Most common areas of decubitus ulcer?

Answer 28

Sacrum, heel, ischial tuberosities, greater trochanters, heels, lateral malleolus (lateral \> medial)

Question 29

If a stage III decubitus ulcer begins to heal and becomes only apparent with erythema and induration what stage would this be?

Answer 29

Still a stage III, once it has been classified at it's worse that stage sticks

Question 30

What is the treatment for stage IV decubitus ulcers?

Answer 30

Surgical management

Question 31

Treatment in general for decubitus ulcers?

Answer 31

Frequent rotation/minimization of pressure on sites, good wound care with occlusive dressing

Question 32

What risk factors are strongly associated with diffuse dermal angiomatosis?

Answer 32

Smoking and vascular atherosclerosis

Question 33

What are the most common sites for diffuse dermal angiomatosis?

Answer 33

Legs, breasts, forearms (breasts often used as an example on test)

Question 34

What is the clinical presentation of an arteriosclerotic ulcer of Martorell?

Answer 34

These start as a painful red blister that then progresses to a blue purpuric lesion and then ulceration. ## Footnote The ulcer is usually superficial w/ necrotic base and violaceous-erythematous edges, but may be deep or enlarging too

Question 35

What is the most common location of an arteriosclerotic ulcer of Martorell?

Answer 35

On the anterior or medial lower leg

Question 36

What are arteriosclerotic ulcers of Martorell associated with?

Answer 36

Severe HTN

Question 37

What is the histology of an arteriosclerotic ulcer of Martorell?

Answer 37

Thickening of arteriole media and intima sometimes with hyalinosis/calcinosis of media.

Question 38

What is the treatment of arteriosclerotic ulcer of Martorell?

Answer 38

Controlling HTN, compression stockings, and good wound care

Question 39

What are some hematologic causes of ulcers?

Answer 39

- Hemoglobinopathies (sickle cell for example) - Clotting abnormalities: vactor V Leiden def, protein C/S deficiency, anti-phospholipid syndrome, etc - Ulcers related to hematologic malignancy: Pyoderma gangrenosum, vasculitis, type I cryoglobinulemia

Question 40

What are some inflammatory causes of ulcer?

Answer 40

PAN, RA/Felty's syndrome, pyoderma gangrenosum, necrobiosis lipoidica, Behcet's, ulcerative LP, ulcerative sarcoid, lividoid vasculopathy, panniculitis (see respective sections for further discussion of these

Question 41

What are 3 examples of angioinvasive fungi?

Answer 41

Zygomycosis, fusarium, aspergillosis

Question 42

What cancers can cause ulceration?

Answer 42

Almost any, SCC most common, BCC, lymphomas, Kaposi's, angiosarcoma.

Question 43

What metabolic conditions can cause ulcer?

Answer 43

Depositional things can cause ulcer (calcinosis cutis, gout) adjacent to joints, if you see necrotic ulcer in areas with more fat content can consider calciphylaxis

Question 44

What are some genetic forms of ulcers?

Answer 44

Adams-Oliver syndrome: aplasia congenita cutis (scalp most often) Prolidase deficiency: hallmark of disease is severe, chronic, recalcitrant, painful skin ulcers mostly located on the lower extremities, especially the feet. These occur early in life (as early as 6 months) or as late as 30 Familial tumor calcinosis: the eruption of rapid small acrally located calcified nodules leading to ulceration. Pain is bad Werner syndrome (leg ulcers): Also known as progeria, causes pre-mature aging and increased risk of cancer and other diseases. Signs usually manifest in teenage years or childhood Flynn-Aird syndrome: AD, skin atrophy and ulcers cataracts and multiple neural issues (retinitis pigmentosa, sensorineural hearing loss, ataxia, peripheral neuritis, epilepsy, dementia Klinefelter syndrome (leg ulcers): low testosterone leads to elevated PAI-1 and increased activity of this is implicated in causing ulceration (leg ulcers, can be presenting sx)

Question 45

What medications are implicated in causing ulcers?

Answer 45

Hydroxyurea (common): malleolus, tibial crest, painful Interferon (injection sites) Methotrexate in psoriasis Anticoagulants: warfarin (secondary to acquired protein C deficiency) and heparin necrosis (secondary to HIT)