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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


  • Skin infarction (thrombotic ulcer)

  • Vasculitis-RA, SLE, scleroderma


  • Post herpetic ulcer

  • Tuberculosis


  • Tropical ulcer

  • Post cellulitis


  • Primary-SCC, melanoma, malignant change in ulcer

  • Secondary-ulcerating metastases


  • Haematological e.g. sickle cell

  • Chronic scarring—sun damaged skin

  • Pyoderma gangrenosum

Pitfalls (often missed)

Insect and spider bites

Factitious (neurotic excoriations)


  • 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. Check for a history of intermittent claudication or ischaemic rest pain; chronic ulcers including sun damage; tropical residence. Include a drug history, esp. beta blockers, corticosteroids, ergotamine, nifedipine.

Key examination

  • General features: appearance of patient, vital signs esp. temperature

  • 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


  • blood sugar


  • 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.

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