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Probability diagnosis

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Traumatic ulcer

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Decubitus (related to trauma)

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Venous insufficiency

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Arterial insufficiency

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Mixed venous and aterial

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Serious disorders not to be missed

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Vascular:

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  • post-thrombophlebitis

  • arterial insufficiency

  • skin infarction (thrombolytic ulcer)

  • vasculitis:

    • — rheumatoid arthritis, SLE, scleroderma

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Infection:

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  • tropical ulcer

  • tuberculosis

  • Mycobacterium ulcerans

  • postcellulitis

  • chronic infected sinus

  • AIDS

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Malignant:

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  • squamous cell carcinoma

  • Marjolin ulcer (SCC)

  • basal cell carcinoma (rodent ulcer)

  • malignant melanoma

  • ulcerating metastases

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Haematological:

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  • spherocytosis

  • sickle cell anaemia

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Neurotrophic:

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  • peripheral neuropathy (e.g. diabetes)

  • peripheral nerve injuries (e.g. leprosy)

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Other causes:

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  • pyoderma gangrenosum (diagnosis of exclusion)

  • insect and spider bites

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Masquerades checklist

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Anaemia

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Diabetes

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Drugs (e.g. illicit drugs)

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Is the patient trying to tell me something?

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Consider artefactual ulceration, i.e. factitious.

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Key history

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A careful history helps determine the cause of the ulceration. Relevant history includes previous deep venous thrombosis or pulmonary embolism, diabetes, rheumatoid arthritis, inflammatory bowel disease, chronic skin ulcers and arterial insufficiency, including a history of intermittent claudication and ischaemic rest pain.

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   A drug history is important, considering especially beta-blockers and ergotamine, which can compromise the arterial circulation, corticosteroids, and NSAIDs, which affect healing.

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Key examination

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  • Any ulcer should be assessed for the following characteristics: site, shape, size, edge, floor, base, discharge, surrounding skin, regional lymph nodes

  • Assess the circulation: venous and arterial

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Key investigations

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The following should be considered, according to the clinical findings:

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  • full blood count

  • ESR, CRP

  • random blood sugar

  • rheumatoid factor tests

  • duplex Doppler ultrasound

  • swab for specific organisms

  • biopsy, especially if SCC suspected.

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Diagnostic tips

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  • The great majority of leg ulcers are vascular in origin due to arterial insufficiency or venous hypertension.

  • If clinical findings don’t provide the diagnosis, ordering the ankle brachial index (ABI) is essential if pulses are not palpable to exclude arterial disease. Duplex Doppler ultrasound is the key investigation for venous disease.

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