11/14/24, 10\:58 AM Leg Ulcers

Leg Ulcers

Table of contents
Key points ⚡
Succinct notes to superpower your revision
Leg ulcers\: common in clinical practice, important to di
ABPI\: used to di
ABPI.
Arterial ulcers\: caused by inadequate blood supply, often due to atherosclerosis. Occur on toes/heels, are painful, pale,
"punched-out"
, with absent pulses. ABPI \< 0.8. Managed with wound care, lifestyle changes, and possible vascular
reconstruction.
Venous ulcers\: result from chronic venous insu
painful when standing, with shallow, irregular borders. Compression therapy and wound care key to management.
Neuropathic ulcers\: seen in diabetes due to peripheral neuropathy, occur on weight-bearing areas, painless, variable size.
Managed with wound care, o
Vasculitic ulcers\: result from in
systemic vasculitis signs. Biopsy con
Infected ulcers\: exhibit purulent discharge, erythema, swelling, and may have systemic infection signs. Treated with
prolonged antibiotics and wound care.
Malignant ulcers\: non-healing ulcers that transform into squamous cell carcinoma. Features include rapid growth, irregular
borders, friability. Biopsy essential for con
Article 🔍
A comprehensive topic overview

Introduction

Leg ulcers are common in clinical practice and OSCEs and can occur in various forms. It is important to be able to clinically
di
This article provides an overview of the pathophysiology, clinical features, investigations, and management of di
types of ulcers.
Assessment of leg ulcers
When assessing ulcers in clinical practice or an OSCE scenario, key steps include\:
1,2
1. Asking about the symptoms experienced (onset, progression, and severity)
2. Identifying risk factors, such as immobility and a history of deep vein thrombosis
3. Examining the wound (site, edge, size, depth, wound bed, and look for signs of infection)
4. Examining both legs (for oedema, varicose veins, venous skin changes, peripheral neuropathy and reduced ankle
mobility)
5. Assessing for other causes of ulceration and/or delayed wound healing
6. Measuring the ankle-brachial pressure index in both legs to exclude arterial insu
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Arterial ulcers

Arterial ulcers, also known as ischemic or arterial insu
extremities.
The primary culprit is atherosclerosis, leading to arterial narrowing and compromised blood
perfusion deprives tissues of oxygen and nutrients, resulting in tissue damage and ulceration.
1,3

Clinical features

Location\: Arterial ulcers predominantly occur on the lower extremities near end-arteries, particularly the toes, heels, and
lateral malleolus.
Pain\: Patients frequently endure severe, resting pain due to ischemia. Painful, especially at night, and worse when legs are
elevated.
Appearance and features\:
Arterial ulcers often appear pale, dry, and gangrenous, with cool surrounding skin
These ulcers are sharply de
Loss of hair on surrounding skin (shiny appearance)
Pulses\: Diminished or absent pulses, especially in the a

Investigations

Relevant investigations for arterial ulcers include\:
Doppler ultrasound\: this non-invasive test assesses blood
Ankle-Brachial Pressure Index (ABPI)\: measures the ratio of systolic blood pressure at the ankle to that in the arm. An
ABPI \<0.8 indicates arterial insu
Angiography\: invasive angiography may be necessary to visualize arterial anatomy and plan interventions.
1

Management

The management of arterial ulcers comprises wound care and lifestyle modi
contributing to arterial insu
Good analgesia to control ischaemic pain and lifestyle promotion, including encouraging smoking cessation, exercise,
and control of comorbidities, are important
ulcer development.
Proper wound management of any existing ulcers is important, and dressings should maintain a moist wound
environment. This may require input from tissue viability teams.
Caution
Compression bandaging and anti-embolism stockings are contraindicated if arterial ulcers are present, as this could
further reduce distal blood
Vascular reconstruction via surgical bypass or angioplasty procedures can restore blood
tissue to aid wound healing.
Figure 1. Arterial ulcer
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Venous ulcers

Venous ulcers arise from chronic venous insu
oxygenation, triggering in
Chronic venous insu
elevation of venous pressures. This most commonly results from venous re
a long-term sequelae of deep vein thrombosis or varicose veins.
1,3,4

Clinical features

Location\: Venous ulcers typically form around the medial or lateral malleolus (more common over medial than lateral).
History of venous disease (e.g. varicose veins, deep vein thrombosis).
Pain\: Patients often report aching or heaviness in the a
with leg elevation.
Appearance and features\:
1
Venous ulcers are usually shallow with irregular borders.
Accompanied by oedema, erythema, and hemosiderin deposition in the surrounding skin (brown pigment).
Lipodermatosclerosis, and atrophie blanche (white scarring with dilated capillaries)
Skin is likely to be warm
Pulses\: Pulses generally remain normal in venous ulcers.
Figure 2. Venous ulcer
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Figure 3. Example of venous skin changes and a venous ulcer in brown skin

Investigations

Relevant investigations for venous ulcers include\:
1
Doppler ultrasound\: to exclude underlying arterial disease and assess venous re
Venous duplex ultrasound\: provides comprehensive information about venous anatomy and re
Venous pressure measurement\: Invasive venous pressure measurement can con
is rarely performed clinically

Management

Lifestyle modi
cases, regular exercise, and avoidance of prolonged standing or sitting can all help to improve venous su
of the legs will also support venous return, so patients should be encouraged to elevate their legs whenever possible.
In contrast to managing arterial ulcers, compression therapy is a mainstay in managing venous ulcers.
However, arterial insu
in the reduction of venous hypertension and promotes venous return. This needs to be maintained long-term.
Lastly, wound care for healing ulcers should be prioritised in these patients. Moist dressings facilitate wound healing. Non-
viable tissue may necessitate debridement. Frequent use of emollients should be encouraged.
2,5

Neuropathic ulcers

Neuropathic ulcers, also referred to as diabetic foot ulcers, develop due to peripheral neuropathy and pressure-related
trauma.
Patients with diabetes often experience neuropathy, which leads to reduced sensation in the a
pressure and friction can then cause tissue breakdown and ulcer formation.

Clinical features

Location\: Neuropathic ulcers frequently appear on weight-bearing foot areas (e.g. plantar surface).
History\: Patients usually have a history of diabetes or neurological disease
Pain\: These ulcers are often painless due to sensory neuropathy. Patients may not notice the ulcer until it becomes severe.
Appearance and features\:
Variable size and depth. Surrounding skin may be warm, dry, and calloused.
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Typically occur in numb skin
Pulses\: Pulses are usually present and normal in neuropathic ulcers, although they can be absent if there is concomitant
arterial insu

Investigations

The diagnosis is primarily clinical, considering the patient's history and physical examination neurological
examination can assess sensory loss to con
1
X-rays may be used to exclude osteomyelitis in chronic or non-healing ulcers.
1

Management

Wound care is crucial to maintain a moist wound environment with appropriate dressings. Tissue viability nurses can
support with dressing choice, and these patients may also be seen in a dedicated foot clinic.
Debridement may be necessary for callused tissue. In this patient population, o
footwear or total contact casting is crucial to prevent further trauma and relieve pressure on the wound.
Glycaemic control and optimisation of diabetes management should be reviewed in these patients to slow the
progression of neuropathy.
1,3,8,9
Figure 4. Diabetic foot ulcer

Vasculitic ulcers

Vasculitic ulcers, often purpuric and punched out, stem from in

Clinical features

Appearance\: Purpuric, punched-out lesions. Biopsy shows vasculitis of medium-sized vessels.
Pain\: Very painful and fast-evolving
Patients may have systemic signs of vasculitis, such as fever and joint pain.
8

Infected ulcers

Infected ulcers occur when bacteria invade the wound, causing purulent discharge and potential systemic infection.

Clinical features

Patients may show signs of systemic infection (e.g. fever and malaise).
8
The ulcer may exhibit purulent discharge, erythema, warmth, and swelling. It is also accompanied by new onset or
worsening pain.
Monitoring for infection
In any ulcer, it is important to monitor for infection and treat it promptly. Antibiotic courses may need to be prolonged
to 10-14 days, and di
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Malignant ulcers

Malignant transformation can occur in long-standing non-healing ulcers, such as the development of squamous cell
carcinoma.

Clinical features

Clinical features of malignant transformation include irregular border, rapid growth, friable, and contact bleeding.
A tissue biopsy is essential to con
8

Summary

In clinical practice, ulcers can exhibit a mixture of arterial, venous, and neuropathic components, making accurate
diagnosis and management challenging.
ABPI results can aid in distinguishing these ulcers\:
Arterial ulcers typically have an ABPI \<0.8, indicating arterial insu
Venous ulcers generally have an ABPI >0.8, re
Neuropathic ulcers are typically associated with normal ABPI values
For vasculitic ulcers, infected ulcers, and malignant ulcers, ABPI results may vary, but the focus should be on clinical
assessment, tissue biopsy (if malignancy is suspected), and appropriate investigations for vasculitis or infection.
Arterial ulcer Venous ulcer Neuropathic ulcer
Aetiology
Develop as a result of
inadequate blood
supply to the
extremities
Result from chronic
venous insu
due to persistent
elevation of venous
pressures
Develop due to
peripheral
neuropathy and
pressure-related
trauma.
Deep,
‘punched-
out’ appearance
Clinical
features
Pulses diminished
or absent
Shallow with
irregular borders,
accompanied by
venous skin
changes.
Variable size and
depth. Surrounding
skin may be warm,
dry, and calloused.
Skin likely to be
cool
Pulses generally
remain normal
Typically occur in
numb skin
Skin likely to be
warm
ABPI/
investigation
s
ABPI \<0.8 indicates
arterial insu
Doppler ultrasound
can assess blood

arterial stenosis
Normal ABPI values
(0.8-1)
Doppler ultrasound
can exclude
underlying arterial
disease and assess
venous re
Typically
associated with
Normal ABPI values
(0.8-1)
Neurological
examination can
assess sensory loss
to con
neuropathy.
X-rays may be used
to exclude
osteomyelitis in
chronic or non-
healing ulcers.
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References

British Association of Dermatologists (2020) D e r m a t o l o g y \: a h a n d b o o k f o r m e d i c a l s t u d e n t s & j u n i o r d o c t o r s . Available from\:
[LINK]
NICE (2023) V e n o u s L e g U l c e r s . Available from\: [LINK]
DermNet NZ (2004b) L e g u l c e r , D e r m N e t . Available at\: [LINK]
BMJ Best Practice (2023) C h r o n i c v e n o u s i n s u LINK]
d i a g n o s i s a n d t r e a t m e n t | B M J B e s t P r a c t i c e . Available
DermNet NZ (2004) C o m p r e s s i o n t h e r a p y , D e r m N e t . Available from\: [LINK]
Skinsight (2023) S t a s i s u l c e r ( v e n o u s u l c e r ) \: C a u s e s , s y m p t o m s , & t r e a t m e n t , S k i n s i g h t . DermNet NZ (2007) L e g u l c e r i m a g e s , D e r m N e t . Available from\: [LINK]
DermNet NZ (2016) D i LINK]
NICE (2015) D i a b e t i c f o o t p r o b l e m s \: P r e v e n t i o n a n d m a n a ge m e n t \: G u i d a n c e . Available Image references
Figure 1. Jonathan Moore. Arterial ulcer peripheral vascular disease. License\: [CC BY]
Figure 2. Dermnet. Venous ulcer. License\: [CC BY-NC-ND]
Figure 3. Ashashyou. Chronic venous insuCC BY-SA]
Figure 4. Dermnet. Diabetic foot ulcer. License\: [CC BY-NC-ND]
Available from\: [LINK]
from\: [LINK]

Reviewer

Dr Shabana Habib
Dermatology registrar

Related notes

Acne vulgaris
Basal Cell Carcinoma (BCC)
Cellulitis
Cutaneous Squamous Cell Carcinoma (SCC)
Erythema Multiforme

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Contents

Introduction
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