Probability diagnosis
Venous insufficiency 52%
Arterial insufficiency 13%
Mixed arterial and venous disease 15%
Pressure sore
Trauma with chronic infection
Systemic disease esp. diabetes
Secondary to peripheral oedema
Serious disorders not to be missed
Vascular:
- Skin infarction (thrombotic ulcer)
- Vasculitis-RA, SLE, scleroderma
Infection:
- Post herpetic ulcer
- Tuberculosis
- HIV/AIDS
- Tropical ulcer
- Post cellulitis
Cancer:
- Primary-SCC, melanoma, malignant change in ulcer
- Secondary-ulcerating metastases
Other:
- Haematological e.g. sickle cell
- Chronic scarring—sun damaged skin
- Pyoderma gangrenosum
Pitfalls (often missed)
Insect and spider bites
Factitious (neurotic excoriations)
Rarities:
Tropical infections e.g. leprosy
Myobacterium ulcerans
Masquerades checklist
Diabetes: neurotrophic
Drugs—systemic reaction
Anaemias: hereditary anaemias
Is the patient trying to tell me something?
Consider: Factitious ?dermatitis artefacta ?neurotic excoriation
Key history
Look for a cause:
- venous—previous DVT
- varicose veins
- peripheral arterial disease
Seek history of systemic disease such as;
- diabetes
- inflammatory bowel disease
- connective tissue esp. RA.
Hx of intermittent claudication or ischaemic rest pain; chronic ulcers including sun damage; tropical residence.
Drug hx, esp. beta blockers, corticosteroids, ergotamine, nifedipine.
Key examination
General features: appearance of pt, vital signs esp. temp
Full cardiovascular assessment esp. lower limb
Assess characteristics of the ulcer, esp.
- shape
- edge
- floor
- discharge
- surrounding skin
- regional lymph nodes
Neurotip or similar for skin sensation
Key investigations
First line:
- FBE
- ESR/CRP
- blood sugar
Consider:
- wound swabs (if evidence infection)
- duplex ultrasound
- ankle brachial index
- biopsy
- KFTs
Diagnostic tips
Be cautious of almenotic melanoma if undertaking biopsy.
If the ulcer and site is painful, consider arterial insufficiency.
