Other conditions associated with leg ulcers and common in written exams - Sickle cell disease, Cryoglobulinaemia, Spherocytosis.
- Venous Ulcers
- These are classically seen above the medial malleolus may involve the complete circumference of the lower leg and often are bilateral. Often a history of varicose veins or DVT
- Ulcers are chronic and long term and can take a long time to heal. Pink granulation tissue. Patients are usually sent home for care and dressing by the district nurse service.
- Best to avoid systemic antibiotics unless good signs of infection such as a clear rim of cellulitis.
- If the ABPI is >0.8 then use graduated compression stockings to improve venous return. The legs will need elevation and regular compression dressings as required depending on the extent of exudate and how clean the ulcer is and its size. There are various topical agents used and steroid creams may be required for surrounding dermatitis.
- Enlist specialist help early. Focus on nutrition and don't heal the ulcer at the price of reduced mobility. Also, access for venous thromboembolism prophylaxis especially if immobile in hospital.
- Arterial ulcers
- Tend to occur and distal toes and pressure areas and over the lateral malleolus and over the dorsum of the foot and heads of metatarsals. Often tender and punched out the edge. Cold.
- An ABPI of >0.8 suggests good vascular supply. However, there can be microvascular and macrovascular problems in diabetics and smokers. Atherosclerosis, Buerger's disease.
- May need a referral to vascular for assessment. In some cases, vascular bypass procedures and angioplasty can help but in many cases the only treatment is amputation.
- Vasculitis ulcers
- Vasculitic ulcers are usually seen over the tibial tuberosity and can easily be mistaken for venous ulcers. Look for associated diseases.
- Traumatic ulcers
- Due to diabetics or others standing on items and neuropathy or poor footwear. They may not recall a trauma.
- Neuropathic ulcers
- Usually found in areas with impaired sensation such as the heel and plantar surface of the foot where the foot is exposed to trauma and there is sensory loss.
- Often seen in diabetics and those with peripheral neuropathy or alcoholism
- Malignant ulcers
- Always beware the ulcers that don't heal. If any doubt they need a biopsy.
- A squamous cell cancer can develop in a venous ulcer and is known as Marjolin's ulcer and is easily missed. These will need wide local excision
- Pyoderma gangrenosum
- Can cause severe ulceration and worsened by surgical intervention. Red violaceous borders.
- Pain be associated inflammatory bowel disease or other associations.