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162 ATYPICAL CAUSES OF LEG ULCERATION
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TABLE3.10
Allergic contact dermatitis
Varicose eczema
Bacterial folliculitis
Pustular psoriasis
Pyoderma gangrenosum
Bullous pemphigoid
Malignancy
Cellulitis
Venous ulceration
Source: Adapted from Conde (2015) and Nichol etal. (2017).
Possible dierential diagnoses oferosive pustular dermatosis.
recognised and can be confused with other lower limb conditions, as
indicated in Table3.10 (Duus- Grovell2021; Conde2015), therefore
the exact incidence and prevalence of EPD are unknown
(Conde 2015). EPD is thought to be most commonly seen in
individuals who are elderly, female and have a history of chronic
venous insuciency (Lee et al. 2020; British Association of
Dermatologists2022).
The exact cause of EPD is unclear, but it is thought to be triggered
by sun damage or as a result of skin injury (e.g. previous surgery or
trauma). On the leg, EPD is often accompanied by venous stasis or
atrophy and is not uncommon in those having long- term compression
therapy (Dawn etal.2003). It can be confused with cellulitis (Zhou
et al. 2015) but has unique characteristics that determine its
management. Nicol et al. (2017) indicated that there is a strong
association between the development of EPD and the chronic
inammation that is associated with venous insuciency. Other
proposed causative factors are neutrophil dysfunction, zinc deciency
and occlusion with compression bandaging (Conde 2015; Di
Altobrando etal.2020).
Examination
EPD usually occurs on the gaiter region of the limb and can be
unilateral or bilateral. The condition typically presents with
supercial crusted erosions and multiple pustules with sterile pus to
surrounding skin (Figure 3.16); the removal of the crusts reveals
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FIGURE3.16 Pustules and crusted areas to surrounding skin.
Source: Erdmann etal. (2009) / John Wiley & Sons. Reproduced
withpermission.
shiny granulation tissue (Nichol etal.2017; Di Altobrando etal.2020)
after the removal of the frank pus.
Left untreated, areas of EPD simply increase and join up to form
larger, shallow erosive lesions; the condition has been described as
having ‘pustular lakes’ (Bull and Mortimer1995). On the leg, it is not
uncommon to nd circumferential patches of crusty fragile scabs or
ragged erosive areas from ankle to knee. When scabs are absent the
clinical features have similarities to cellulitis. Large erosive areas are
often wrongly described as ulceration.
Investigations
Histology from a biopsy of the lesions is often non- specic and may
reveal inltration of polynuclear neutrophils in the dermis (Nichol
etal.2017; Reschke etal.2021). Reschke etal. (2021) proposed that
the presence of these inammatory cells (possibly attributed to
trauma in the area) contributes to exacerbating the cycle of
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inammation, resulting in poor healing. A biopsy of the area may
also be helpful to exclude other possible wound aetiologies
(Conde2015).
Wound swabs are not usually indicated and can be misleading in
the treatment of EPD. The swab results often reveal secondary
colonisation with bacteria and fungi such as Staphylococcus aureus
and Candida albicans rather than a primary cause of infection (Zhou
etal.2015; Nichol etal.2017). A study by Dawn etal. (2003) found
54% of patients to have laboratory evidence of fungal infection that
cleared after antifungal treatment. The remaining participants
achieved clearance with topical steroids and interestingly a change in
management from multilayered ‘fourstretch regime.
Arterial status should be established using a Doppler ultrasound
to calculate the ABPI and will assist in guiding suitability for compression therapy (Wounds UK2016).
layer’ compression to a long-
Diagnosis
There are currently no specic clinical criteria for the diagnosis of
EPD and presenting clinical features may be similar to other aetiologies, thus reaching an accurate diagnosis can be challenging (Nichol
etal.2017). Table3.10 indicates possible dierential diagnoses to be
considered. Diagnosis of EPD is often made following exclusion of
other possible aetiologies and failure to respond to previous management such as dressings, compression and antimicrobials (Conde2015).
EPD is most commonly misdiagnosed as cellulitis, since the clinical features such as pustules, suppurative exudate with crusts and
erosions, as well as a positive swab result, can be present in both aetiologies (Zhou etal.2015). EPD therefore should be considered as a
dierential diagnosis of exclusion for patients who have not
responded to local or systemic antibiotics for the treatment of suspected cellulitis (Zhou etal.2015).
Intervention
The evidence to support best practice in treating EPD is currently
lacking and further research to support clinical pathways is needed
in this area. There is currently no cure for this condition
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and treatment will depend on accurate and early diagnosis
(British Association of Dermatologists2022). Involvement in the
appropriate clinical team such as dermatology can assist in
devising an appropriate treatment plan (British Association of
Dermatologists2022).
Clinical management is aimed at removing the crusts, treating
the erosions with topical therapy and allowing them to dry out and
heal (British Association of Dermatologists 2022). Removal of the
crusts can be done by using a skin cleansing cloth, debridement pad
or simple lifting of the scab with forceps. It should not create any
pain for the patient. The removal of the scab will release the tell-
tale
sign of pus and then the erosion needs to be cleansed. The erosive
area can be friable and thus the patient can be positioned forward so
as not to cause alarm; any bleeding should stop swiftly and extra care
must be taken not to create any skin tears in the atrophied skin. The
next step is the application of the topical treatment; this can be problematic on wet erosions, so the practitioner or patient may nd it
useful to apply the ointments to the non- adherent dressing rst and
then to the limb.
Topical Treatments
High- potency topical steroids have been found to be one of the
most eective treatments (British Association of Dermatologists2022; Nichol etal.2017; Zhou etal.2015).
Topical tacrolimus 0.1% does not cause skin atrophy, unlike cor-
ticosteroids, and is often used in conjunction with corticosteroids
or prophylactically to prevent recurrence (Conde2015).
Oral Treatments
Retinoids or zinc supplements can be used (British Association of
Dermatologists2022).
Local Wound Care
Initially gentle removal of the crusts and daily dressings with a nonadherent dressing are advised (British Association of Dermatologists2022; Conde2015).
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Compression Therapy
Compression therapy is recommended to manage the venous
insuciency (Wounds UK2016) that is commonly present in EPD.
However, it was surmised by Dawn etal. (2003) that continuous use
of compression therapy with fourto a potential risk of developing a fungal infection and poor progress
of wound healing. Dawn et al. further suggested that patients
responded better when intermittent short- stretch bandaging was
used as opposed to continuous four- layer bandaging. It has to be
recognised, however, that their study is from 2003 and the types of
compression therapy available today are more extensive and may not
have the same outcomes should a similar study be conducted (refer
to Chapter7 for the types of compression available). Indeed, the
suggestion was not supported by a more recent study by Nichol etal.
(2017), who concluded that compression hosiery was not a
contributory factor to poor healing in EPD patients once treatment
with topical corticosteroids had been commenced. Nevertheless,
careful consideration should be given to the type of compression, as
the topical treatments and removal of crusts will initially be required
to be undertaken daily and compression bandaging may not be the
best option, especially if the patient is willing and able to perform
self- care.
layer bandaging could contribute
Patient Self- Care
It is critical to recognise that EPD is often a life- long skin disorder
and can be experienced as a recalcitrant condition on the lower leg
(Brouard etal. 2002), thus it is imperative that a self- management
schedule is instigated as soon as an eective treatment regime is
identied. It is unlikely that an eective regime will follow a linear
pattern or achieve complete resolution. Therefore, enabling and
empowering the patient to manage their care and condition if they
are able are important aspects of treating EPD due to its often lifelong and recurring nature. Treatment regimens are also required
daily both in the early stages of treatment and for prevention of
recurrence. Thus visiting a healthcare establishment or waiting for
community nursing visits can become arduous and aect the individual’s quality of life.
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Some considerations and advice for patients with EPD are:
Ensure the patient has an understanding of EPD and treatment
options that are available.
Assess the patient for their willingness and ability to undertake
self- care.
Develop an appropriate treatment plan in collaboration with the
patient (see Box3.1).
Identify red ags and who to contact in the event of any concerns.
Organise a follow- up appointment for review with whoever is
overseeing the care of the patient. This should include
dermatology.
Once the condition has healed, patients should be given advice
on maintenance of the skin and prevention of recurrence. This
may be short term using tacrolimus 0.1% twice a week, emollients
Box 3.1 Self- management of EPD
Skin care should be carried out using debridement cloths or
similar to remove scabs and cleanse the erosive areas. Bathing
with an emollient should be encouraged.
Help the patient understand what they are experiencing and
provide resources such as the British Association of Dermatologists
information leaet. This will give the patient condence in their
self-
management of the scabs and treatment of the erosions and
surrounding skin with the prescribed topical treatments and
emollients. They will learn how to respond to any are- ups of the
condition.
If oedema is signicant, then use compression bandages, but
for a limited period only in order to reduce the oedema:
A moderate dose of compression is often therapeutic for these
conditions.
A nurse- led bandage regime can promote dependency; the
nurse will be providing the skin care and application and in
this often recalcitrant condition it can prove dicult to break
this pattern of treatment.
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A self-
management regime is focused on:
Maintaining a skin care regime and removal of scabs.
Use of a zinc oxide–impregnated stocking under a compression
liner sock.
A hosiery garment at the prescribed dose of compression.
Protection from further sun damage.
Self- management of relapses, but swift access to medical
support when required.
and compression hosiery to manage venous insuciency and
protecting the skin from further sun damage (British Association
of Dermatologists 2022; Conde2015).
Factitious/Artefactual Ulcers andSelf- Harm Wounds
Factitious ulcers, artefactual ulcers or self- harm wounds have been
described as ‘The deliberate and conscious production of self- inicted
lesions to satisfy an unconscious psychological or emotional need’
(Isoherranen etal. 2019). These wounds can also be referred to as
dermatitis artefacta.
These types of wounds can occur on any part of the body that is
easily accessible to the patient. Diagnosis is often dicult, as the
patient’s history can be vague and may not always t with the appearance of the wound itself (Isoherranen etal.2019). The motivation
for patients to cause wounds to themselves can be complex and may
be triggered by deep psychological stress. Triggers may include
trauma, psychological disorders and sexual or physical abuse
(Hunt2017).
History
It can be dicult to obtain an accurate history from the patient, who
may be vague about the way the wound occurred (Kilroy- Findley and
Bateman 2016). A previous history of multiple attendances to the
hospital’s emergency department, and a history of mental illness or
psychological trauma, may raise suspicion that the wound is due to
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self- harm (Hunt 2017). If possible, the method of how the wound
was caused should be established.
Examination
The more typical features of how self-
harm wounds may present
clinically are as follows:
The wounds may be in areas that are easy for the patient to reach
and uniform in shape.
The appearance of the wound may vary depending on the method
of injury (Figure3.17 indicates continual gouging or scratching
of the area).
Infection may be suspected if an unclean implement was used to
cause the injury.
There may be scarring or evidence of previous historical wounds
to surrounding skin.
FIGURE3.17 Leg wounds due to self- harm with continual gouging/
scratching of the area.
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Investigations
Investigations are not usually required for this type of wound,
especially at rst presentation. However, wound infection is a
common occurrence of a factitious wound (KilroyBateman2016). The development of wound infection may be linked
with how the injury was caused, for instance by unclean instruments
or dirty ngernails, environmental factors, or specic patient risk
factors for infection, such as diabetes (see Chapter 5 on infection).
A wound swab may therefore be helpful to identify the pathogen
responsible if the wound is unresponsive to topical antimicrobials or
if spreading infection is suspected, as per local guidelines.
Diagnosis
Diagnosis can be challenging, especially if the patient withholds key
information on how the wound occurred and their past medical
history. Diagnosis is therefore often made after exclusion of other
wound aetiologies (Isoherranen etal.2019).
Intervention
A patient’s mental state may inuence their ability to engage with
treatment options (Kilroy- Findley and Bateman2016). NICE (2022b)
suggests that HCPs dealing with patients who selffamiliar with and able to apply the principles of the Mental Capacity
Act 2005, Mental Health Act 2007, Care Act 2014 and local
safeguarding procedures, should the patient be deemed to be a risk to
themselves or others (NICE2022b).
It is important to recognise that a factitious wound is often a sign
that an individual is experiencing psychological distress (NHS
Choices2015). The treatment will involve understanding triggers for
self- harm and providing a referral for support and guidance. This
may be to the local mental health team or one of the many thirdsector agencies available, such as Mind (NHS Choices2015). Apatient
who self- harms will require the HCP to have empathy and
understanding using a non- judgemental approach to gain the
patient’s trust (Hunt 2017). An understanding of underlying issues
that have triggered the self- harm is essential, as the patient will need
the correct psychological support to help prevent reoccurrence.
Findley and
harm should be
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NICE (2022b) suggests that an important part of assisting a
patient who self- harms is ensuring that appropriate support and
guidance are given and recommends that information giving
should be:
Tailored to individual needs and circumstances, taking into
account, for example, whether this is a rst presentation or
repeated self- harm, the severity and type of self- harm, and if the
person has any co- existing health conditions, neurodevelopmental conditions or a learning disability.
Provided throughout their care.
Sensitive and empathetic.
Supportive and respectful.
Consistent with their care plan, if there is one in place.
Conveyed in the spirit of hope and optimism.
It may not be possible to stop an individual from self- harming,
therefore management should be centred around reducing harm
(Kilroy- Findley and Bateman2016). This may be achieved by providing patient education in the following areas:
How to reduce the potential for a wound to get infected should
the individual feel the need to undertake self- harm, e.g. by using
a clean instrument during the process and ensuring that it is
performed in a clean environment where possible.
How to recognise the signs of infection and what to do if an
infection is suspected.
How to avoid areas where major blood vessels are present,
reducing the risk of a major bleed.
What to do if a major bleed occurs.
Whom to contact when if the individual has any concerns.
How to access local mental health services and mental health
support groups.
How to redress the wounds appropriately.
A recommended approach to dressing selection is to follow the
principles of moist wound healing with dressings that are acceptable
to the patient, and in many cases allow the individual to self- care if
they need to self- harm (Hunt2017). Covering wounds with occlusive
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