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152 ATYPICAL CAUSES OF LEG ULCERATION
(a)
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(b)
FIGURE3.15 (a, b) Marjolin’s ulcer– SCC transformation in a leg ulcer
originally diagnosed as of venous aetiology. Note the raised edges rolling
outward and exuberant protruding tissue to the wound bed with necrotic
tissue and excess greyish slough.
Source: Enoch etal. (2004) / John Wiley & Sons. Reproduced with permission.
scoring ≥3 being referred via an urgent suspected cancer pathway
(NICE2022a); these lesions are at higher risk of being an MM.
NICE (2022a) recommends that the following should also be referred
through an urgent suspected cancer pathway: nail changes including a
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TABLE3.7
Major features (2 points)
Change in size of the lesion
Change in colour/irregular pigmentation
Change in shape/irregular border
Source: Adapted from Mackie (1990).
Weighted seven- point checklist.
Minor features (1 point)
Inammation
Itch or altered sensation
Larger than other lesions
(diameter
Oozing/crusting of the lesion
>7 mm)
new pigmented line or lesion under the nail; or any persistent or slowly
evolving skin lesion, especially if growing, pigmented or vascular in
appearance, that is unresponsive and with an uncertain diagnosis.
Investigations
Skin biopsy by the dermatology service is the primary investigation
required for any wound showing suspicion of malignancy. The best
practice document on chronic wounds published by the European
Wound Management Association (EWMA) suggests that a biopsy
should be performed on any presumed chronic vascular leg ulcer if
there has been no response to standard treatment after 4–12 weeks
(Isoherranen etal.2019). At least two biopsies taken from the wound
and the wound edge are recommended to ensure that abnormalities
are detected (Senet etal.2012).
Some trained clinicians, such as dermatology specialists and
general practitioners, may undertake dermoscopy in the clinical setting
to check the appearance of lesions more thoroughly. Dermoscopy
involves microscopic examination of the skin surface, allowing trained
clinicians to more closely examine the colour and structure of skin
pigmentation. This can help detect melanomas more easily and
dierentiate them from other skin lesions (Oakley and Stevens2023).
A wound swab should be taken if there are clinical signs of
spreading infection to guide appropriate antibiotic therapy.
Diagnosis
Diagnosis of malignancy in leg ulcers can be identied by examining
the patient history, presence of risk factors, atypical presentation of
the skin, lesion or ulcer and histology reports from a skin biopsy. It is
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recommended to perform at least two biopsies that include the wound
edge and the wound bed to decrease the risk of a false- negative result
from a single biopsy (Isoherranen etal.2019). Sequentially repeated
biopsies may be required to make some formal diagnoses, especially
if previous biopsy results have been negative but the wound continues
to look or behave suspiciously (Isoherranen etal.2019).
Staging examinations, such as ultrasound, computed tomography
(CT) or magnetic resonance imaging (MRI) scans, may be performed
following diagnosis to detect any spread of cancer to the lymph nodes
or other organs. Results will then be used to guide required treatment,
such as local resection or radiotherapy, or if there is a need for
systemic treatments or chemotherapy (Isoherranen etal.2019).
Intervention
Following referral to dermatology, the usual rst course of action is
surgical excision of the malignant area. Depending on the extent of
the excision required, some areas may require skin grafting to treat
the residual wound.
Also depending on location and depth and if the malignancy has
been identied as having become metastatic or at high risk of spread,
such as with an ulcerated MM, patients may be oered treatment in
the form of radiotherapy and/or chemotherapy (Rice2007). In rare
cases, if the malignancy is especially large or has bony involvement,
major amputation may be required (Trent and Kirsner2003).
With regard to local wound management and preexcision of any area of malignancy, key considerations will be the use of
non- adherent primary dressings to ensure atraumatic removal and primary and secondary dressings with sucient levels of absorption for
the wound exudate levels; compression therapy is required for exudate
management and any accompanying venous hypertension. Symptom
management for issues such as malodour and pain may also be required.
If linked to the presence of necrotic or sloughy tissue, malodour
may be decreased through safe autolytic debridement, although
overtly moist debridement should be avoided if exudate levels are
high. Autolytic debridement may also result in increased exudate,
which can be unsatisfactory to the patient if it is excessive and
dicult to manage and leads to leakage, skin excoriation and
discomfort (Tandler and Stephen- Haynes2017). Other options can
and post-
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Atypical Causes of Leg Ulceration 155
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include topical treatments, such as metronidazole gel or charcoal
dressings in conjunction with antimicrobial dressings. Metronidazole
has been shown to be eective in reducing wound odour, particularly
if the odour is related to an increased bioburden as it has broadspectrum activity. It is particularly eective against anaerobic bacteria
that cause odour (Kavitha etal.2014; Paul and Pieper2008). Charcoal
dressings work by absorbing bacteria and locally released toxins and
chemicals responsible for wound odour (Wounds International2012).
Consideration should also be given to the frequency of dressing
changes required to manage malodour and exudate.
Some malignant wounds will be prone to bleeding; management
with a dressing with haemostatic properties, such as calcium alginate,
may be required. There is also a potential for infection with malignant
leg ulcers. Gentle cleansing with normal saline or water is advised,
particularly if there is a risk of bleeding, and treatment with a topical
antimicrobial dressing as clinically indicated. Some patients may
benet from compression bandaging to reduce oedema following
excision (Todhunter2019).
Tailored patient education on the risks of continued sun exposure
will form part of the individual intervention for patients diagnosed
with any form of malignant leg ulcer as a means of preventing
recurrence (NICE 2016). Patients should be educated on how to
check their skin and have regular follow- up appointments to assess
for further development, spread or recurrence. Consideration should
also be given to the provision of psychosocial support to patients
diagnosed with malignancy.
DRUG- INDUCED LEG ULCERS
Medication- Related Ulceration
Adverse drug reactions are always a potential complication to be
considered when prescribing any medication. This is particularly
pertinent with the current ageing population who have complex comorbidities that require polypharmacy to manage their long- term
conditions (Ramadan 2023). Cutaneous reactions may vary in
appearance from a simple urticaria- type rash to vasculitis and skin
necrosis (Table3.8). Early identication of the severity of the skin
damage and medication that is contributing to the cutaneous drug
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TABLE3.8
andconsiderations toobserve when undertaking assessment.
Drug
Hydroxycarbamide Commonly seen on the lower limb of the malleolus
Methotrexate May present as erythematous eruptions, blisters or
Warfarin
and heparin
Nicorandil Used for the treatment of angina
Common drugs that may cause cutaneous atypical wounds
Considerations to note when undertaking
examination and history
area as a small, dened, painful ulcer
Seen in 10% of patients with
myelodysplastic disorders
May still present after years of hydroxyurea use
Usually resolves after discontinuing the drug
epidermal necrosis
Most seen in psoriasis patients with pre-
psoriatic plaques
May indicate early signs of methotrexate toxicity
Drugs may require discontinuation or
adjustment of dose
Start as erythematous plaques that evolve into
necrotic lesions
Usually appear between days 3 and 10 of treatment
Usually very painful and can be fatal
Treatment involves discontinuation of the drug;
patient may also require initiation of vitamin K
Most ulceration occurs in mucosal membranes, but
60% have been reported in the lower limb
Can be seen from day 2 up to 19 years after
commencing nicorandil
Most episodes of ulceration will resolve following
discontinuation of the medication
existing
Source: Adapted from Nickles etal. (2022); Isoherranen etal. (2019); Babic etal. (2018).
reaction is of paramount importance and may prevent the onset of
more serious reactions that could be life- threatening (Ramadan2023).
Diagnosis of an ulcer that is potentially related to medication
often occurs once other systemic diseases have been excluded, raising
awareness and allowing identication of medication that could
potentially be causing the skin damage.
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Treatment of medication- induced ulcers may require a
multidisciplinary approach and can include stopping the medication
and prescribing antihistamines to reduce side eects such as itching
and corticosteroids to reduce inammation (Ramadan2023). Wounds
usually resolve once the medication has stopped (Isoherranen
etal.2019). Local wound management should follow the principles
of moist wound healing and address the requirements of the local
wound environment (see Chapter5). A more inmediations known to cause ulceration is oered in Chapter8.
depth exploration of
Leg Ulceration inPeople Who Inject Drugs
Drug use in the United Kingdom is estimated to be the highest in
Europe, with people who inject drugs (PWIDs) having far poorer
health outcomes than the general population (UKHSA 2023). It is
thought that approximately 87 000 people aged 15–64in England are
PWIDs (Hay et al.2017), with the most commonly used drug for
injection being heroin (UKHSA 2022), closely followed by crack
cocaine. Crack cocaine is associated with high incidences of skin and
soft tissue infections and is linked to risk factors such as sharing
equipment, groin injecting, higher frequency of injecting, unsterile
injection practices, poor wound care and late presentations of
symptoms (UKHSA2023; Edmundson etal.2021). Injection- related
wounds are common in PWIDs and early detection and treatment
can assist in reducing the possibility of serious complications that
can be life- threatening, such as infection (Sanchez et al. 2021).
However often, there is often a reluctance for PWIDs to seek medical
assistance when a wound occurs and maintaining consistency and
concordance can be challenging. This behaviour often leads to
patients being marginalised within society (Geraghty 2021);
understanding the lived experience is critical to awareness and
management of their conditions.
History
When assessing and treating a person who has a leg ulcer that may be
associated with drug injecting, gaining the individual’s trust and
presenting a non- judgemental approach are of paramount
importance. Very often the lack of engagement of PWIDs with HCPs
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is due to the stigma and discrimination that are often associated with
drug injecting and the lack of knowledge and skills that HCPs may
have surrounding drugunderstanding of how injecting can cause a wound, complications
that may occur following injecting, along with social and mental
health aspects that may aect the individual is an important part of
the knowledge and skill set needed by HCPs treating and managing
PWIDs with wounds.
Wounds in PWIDS can occur due to many aspects, which include
injecting frequently into the same site. Repeated injection into
the veins, especially the femoral vein, can result in signicant
damage to the venous system, leading to CVI, deep vein thrombosis (DVT) development and venous leg ulceration (Doran
etal.2022). Frequent injecting also increases the risk of infection
(Sanchez etal.2021).
Products injected can put the user at higher risk of skin damage
and infection. Certain contaminants in cocaine (e.g. levamisole)
have been linked to vasculitis and skin necrosis (Nickles
et al. 2022). Some mixing agents and contaminants found in
heroin preparations have also been linked to a higher risk of
infection (Sanchez etal. 2021) and acidiers such as citric acid
have been associated with an increased risk of DVT development
(Doran et al. 2022). Neuropathy, nerve damage and muscle
brosis have been associated with the toxicity of the substance
injected and the frequency of injecting (Sanchez etal.2021).
Poor injection techniques may also play a role. Injecting drugs
into the skin rather than into a vein is known as skin popping
and usually is performed when venous access has become
dicult. This technique increases the risk of microvascular and
lymphatic occlusion as well as infection and skin necrosis
(Nickles etal.2022). Attempts to inject into a vein may result in
a ‘missed hit’, where the substance is inadvertently injected
intramuscularly or into the subcutaneous tissue, which increases
the risk of infection (Sanchez etal.2021).
injecting issues (Lang et al. 2013). An
As with any other wound, a full patient history should be
obtained as outlined in Chapter 5. However, there may be specic
questions that may be helpful to gain a better understanding of the
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TABLE3.9
assessment ofpeople who inject drugs (PWIDs).
Substance injected (if known).
Any other recreational drugs that are taken.
Frequency of injecting.
Sites used for injection.
Any previous history of deep vein thrombosis.
Any previous history of wounds associated with injecting sites.
If the patient participates in needle sharing, does the patient have access
to a needle exchange site?
Is the patient under a drug and alcohol team or mental health services?
Is the patient homeless?
Does the patient have access to clean conditions to undertake injections
(this may be particularly relevant if the patient is homeless or lives in
unsanitary conditions)?
Has the patient been screened for human immunodeciency virus (HIV),
hepatitis B and hepatitis C? PWIDs have a high risk of contracting these
infections due to needle sharing (UKHSA 2023).
Aspects ofdrug- taking history that can beincluded inthe
patient’s injecting habits, social circumstances and mental health,
and these may be relevant when implementing a treatment plan.
Table3.9 outlines some questions that may be helpful to consider
during the assessment.
Examination
PWIDs have a high prevalence of venous ulceration due to CVI
(Doran etal.2022). Signs and symptoms of venous disease as outlined
in Chapter 5 may be identied through examination. Ulcer
presentation can often dier from that of standard venous ulceration;
ulceration is typically multiple sites above the ankle to the knee,
including the tibial crest region. The patient should also be assessed
for nerve or muscle damage, impaired calf muscle and ankle joint
function, which may be compromised by frequent injecting into the
lower limb (Sanchez etal.2021).
PWIDs have a high incidence of infection, which increases
signicantly the mortality and morbidity of this population (Sanchez
et al. 2021). Serious complications identied in PWIDs associated
with infection include sepsis, gangrene, amputation and death
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(Sanchez et al. 2021). Bacterial infections that are commonly
associated with poor injecting practices are Staphylococcus aureus,
group A Streptococcus (GAS) and methicillinStaphylococcus aureus (UKHSA 2023). There is also a smaller
potential for toxin- producing bacteria such as botulism, tetanus and
anthrax, which are found in the environment and can contaminate
drugs at any point (UKHSA2023). Vigilance in observing for infection
is therefore of paramount importance in this at- risk group. The signs
and symptoms of infection can be found in Chapter5.
Other symptoms that are often present in PWIDs’ wounds that
have been associated with causing depression and anxiety are high
levels of pain and exudate and malodour (Sanchez et al. 2021).
A large proportion of PWIDs have been identied as being
nutritionally decient, which will have a detrimental eect on the
healing process, therefore a nutritional assessment should be
considered an important part of the holistic assessment.
Investigations
Vascular assessment should be undertaken to identify any
concomitant venous and/or arterial disease in the lower limb, with
appropriate onward referral to vascular for intervention as indicated.
A wound swab may be helpful if wound infection is suspected
(as per local policy) and is not responding to antimicrobial therapy.
sensitive and - resistant
Diagnosis
PWIDs have a high prevalence of CVI and therefore are more at risk
of developing a venous ulcer. However, diagnosis can only be made
using the information obtained from the patient’s history, the clinical
appearance of the wound and the vascular assessment.
Intervention
Management in PWIDs can be complex, as drug- using habits may be
unpredictable and many PWIDs have other health and social issues
such as poverty, homelessness, diculty in getting to venues for
wound dressings and also the stigma and discrimination that they are
often subjected to within the healthcare system (Doran etal.2022).
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Anon- judgemental approach, multidisciplinary working and patient
collaboration are all important parts of the patient’s journey. The main
role of the HCP is to reduce or prevent further harm by signposting
individuals to agencies or services that may be helpful, such as needle
exchange sites, homeless and outreach services and drug and alcohol
support services, as well as discussing aspects of safe injecting such as
not sharing needles.
Local wound management and treatment plans will address
aspects of TIMES as identied within the wound assessment, and
what the patient is identifying as important to them; very often this is
pain and malodour (Sanchez etal.2021). For the HCP early detection
and treatment of infection are imperative and may require treatment
in secondary care if spreading or systemic infection is suspected (see
Chapter5 on infection).
Many PWIDs wish to participate in selfand the HCP is instrumental in supporting this by ensuring that they
are provided with appropriate dressings, given advice on how to
redress the wound to reduce the possibility of infection, how to
identify infection and when to seek help and whom to go to if a
problem occurs. If compression therapy is appropriate, and the
patient is deemed able to cooperate, compression hosiery kits and
compression wraps are products that assist in self- management (see
Chapter8). Even if they are self- caring, patients should always be
encouraged to attend regularly for reassessments with whoever
provides their local wound care management (e.g. practice nurse), to
monitor the progress of the wound and to support the patient with
any ongoing wound issues.
care for convenience,
EROSIVE PUSTULAR DERMATOSIS
Erosive pustular dermatosis (EPD) is a condition that is not widely
recognised outside of dermatology. It is rarely discussed within the
nursing leg ulcer literature, yet is not uncommon within community
leg ulcer management. EPD is challenging to treat and manage
(Duus- Grovell2021).
EPD is a rare chronic inammatory skin condition that occurs
most commonly on the scalp and lower limbs (British Association of
Dermatologists 2022). The presentation of EPD is often poorly
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