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Lower Limb Ulcers: Clinical
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andDiagnostic Workout
VittorioRamella, MartinIurilli, AlessiaDe Grazia,
andLauraGrezar
43
43.1 Introduction andGeneral
Framework
43.1.1 Introduction
Successful treatment of leg ulcers depends on an
accurate diagnosis based on clinical, laboratory,
and instrumental data.
Most of these lesions found in this anatomical
region have an ischemic or venous etiology.
Infectious ulcers are more common in tropical
countries; neoplastic ones are less frequent, but it
is very important to be aware of this possibility at
lastly there are a number of etiologies less common and with a more complex classication.
Ulcers associated with rheumatoid disease
and diabetes are also frequent.
Physical examination should be directed at the
site of the ulcer, its fundus, and edges, before
analyzing the potential venous or arterial
components.
The rst approach in the management of leg
ulcers is represented by an in-depth diagnostic
and clinical picture of the patients and their
lesions.
Early recognition of the ulcer and knowledge
of its various possible etiologies can be a complex path: it is fundamental to identify the potential high-risk patients in order to increase early
prevention features that are the key to lead to the
healing of these wounds in the shortest possible
time, improving outcomes and quality of life, and
reducing complications.
Nonetheless, it is crucial to have an effect on
predisposing factors in order to reduce costs and
hospitalization, most patients are already debilitated considering that many have illnesses such
as diabetes or venous insufciency, and the aim
of the process is to heal them in the fastest time
possible in order to restore their quality of life.
Indeed, the rst approach consists of having a
complete framework of the patient, which
includes vital parameters, the remote pathological anamnesis, even considering their psychosocial status and quality of life, independence in
everyday life, and last but not least the evaluation
of the lesions.
43.1.2 Medical History andClinical
Examination
In the medical history, we proceed with:
identication of any
initial trauma
onset of lesion assessment of comorbidity
progression of signs
and symptoms
previous treatments
identication of previous
loco-regional and vascular
surgery
V. Ramella (*) · M. Iurilli · A. De Grazia · L. Grezar
Plastic Surgery Unit, University of Trieste, Cattinara
Hospital, Trieste, Italy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_43
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On clinical examination, the following are assessed:
the depth the smell
the surface assessment of drainage, if any
the appearance the temperature of the skin
assessment of infection by observation of the presence
of cellulitis or inammation, edema, and markers of
inammation
The “probing to bone” test maneuver should
always be included in the initial assessment of all
ulcers with suspected infection. This test has a
specicity of 85% and a sensitivity of 66% [1].
Other diagnostic tests to determine infection
are deep tissue and/or bone sampling; hematochemical tests such as C-reactive protein and
white blood cell count; and imaging with radiography, CT scan, and MRI.
For the diagnosis of osteomyelitis, the gold
standard is MRI, as radiography is positive
7–15days after onset.
Properly classifying ulcers is essential to
make a correct prognosis, establish proper treat-
ment, plan intervention trials, and facilitate communication and education of healthcare
providers.
The mode of collection of the microbiological
sample is considerably important. The sample
should come from deep tissue or stula drainage
without contact with adjacent skin.
Biopsy of the deep tissue gives more assurance, while syringe aspiration is preferred in case
of vesicles, bullae, or abscesses, and if a swab is
used, it is recommended to “curetect” the lesion
rst. The amount of collection should be sufcient for culture.
The time between collection of the material
and inoculation into the culture medium should
be minimized.
Collections should be made before the administration of antibiotics.
43.1.3 Clinical Diagnostic Criteria
Perilesional
skin Ulcer site Margins
Intact Single or
multiple
Phlegmasic Near foci
of
infection
Macerated Semi-
concealed
sites
Dry Near joints Rounded: capacity to
Near
pressure
points
Sloping: tendency to
heal (e.g., venous and
posttraumatic ulcers)
Stepped: loss of
substance (e.g., trophic
ulcers, venereal ulcers,
residual of skin
necrosis)
Undermined: greater
involvement of the
subcutis than the skin
(e.g., ulcers on
osteomyelitic focus)
invasion (e.g.,
ulcerations caused by
basal cell cancer)
Everted: strong
invasiveness of the
causative disease (e.g.,
ulcerations caused by
squamous cell cancer)
WBP SCORE
Fund
(V.FALANGA)
% granulation 0: dry lesion, dressing
% brin 1: totally controlled,
% necrosis 2: partially controlled,
Essudate WBP SCORE
(V.FALANGA)
MODIFIED Depth
remains adhered to the
fundus
little to no amount,
requires no absorbent
dressing or dressing can
stay in place a week
moderate amount,
dressing can be changed
every 2–3days
3: uncontrolled,
hyper-absorbent wound,
required absorbent
dressing change once or
more per day
Epidermal
Supercial
dermal:
papillary
dermis
Deep dermal:
reticular
dermis
Subdermal
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43.1.4 Instrumental Diagnostic
Criteria
• ABI (ankle-brachial index) or Winsor Index
– <0.4, severe vasculopathy
– 0.4 < ABI < 0.9, mild moderate
vasculopathy
– 0.91<ABI<0.99, uncertain value
– 1<ABI<1.29, normal value
– >1.3, uncompressible arteries with possible
calcications
• TcPO2 (Transcutaneous Oximetry), assessment of tissue oxygenation
– TcPO2>60mmHg, normal
– 30< TcPO2<60 mmHg, functional isch-
emia (associated with stage 2a according to
Leriche Fontain)
– 10 < TcPO2 < 30 mmHg, moderate isch-
emia (associated with stage 2b or 3 according to Leriche Fontain)
– <10 mmHg, severe ischemia (associated
with stage 4 according to Leriche Fontain)
• Eco-Color-Doppler
– In arterial ulcers, it conrms peripheral
obliterative arteriopathy and characterizes
it in terms of stenosis/obstruction, plaque
type, hemodynamics, and lesion pattern.
– In venous ulcers, it allows the assessment
of whether there is obstruction, whether it
is acute or chronic, whether it is supercial
or deep; whether there is thrombotic residual; whether there is supercial or deep
venous insufciency; it can document
whether there is lymphedema and study
regional lymph node stations [2, 3].
• X-ray
• Ultrasound
• MRI
• Lymphoscintigraphy in the investigation of
lymphatic and infectious system diseases
• Angiography: essential when there is intent
for revascularization, but an invasive method,
not without risks such as hematomas, pseudoaneurysms, and arterial lesions.
Winsor Index, which records the ratio of tibial
artery systolic pressure to humeral artery systolic pressure, and TcPO2, which highlights tissue oxygenation of peripheral districts. We
consider critical peripheral ischemia to be that
situation that has indices below the threshold
values of 0.9 for ABI and 30mmHg for TcPO2.
In elderly or diabetic patients, it is not uncommon to nd false negatives, due to the incompressibility of vessels caused by glycosylation or
the presence of calcications, so additional tests,
such as TcPCO2 or the toe-brachial index, where
the abnormal value is considered <6, may be
necessary [4].
If peripheral ischemia is detected by the ABI
index measurement and TcPO2 is present, an
echocolordoppler of the femoro-popliteal-tibial
axis and the arteries proper to the foot (common
plantar, dorsal foot) can be performed. This
examination allows for dening the patency status and any hemodynamic changes of the
femoral- distal arterial axis.
The diagnostic pathway of obstructive arteriopathy can be completed by arteriography. This
examination should be conducted with appropriate timing and exposures in order to visualize the
arteries of the leg and the arteries proper to the
feet.
AngioRMN is an important examination especially when vascular involvement involves other
sites besides the lower limbs, which is indicated
in some special cases for a better denition of the
extent of arteriopathy especially for the purpose
of surgical revascularization.
43.1.5 Laboratory Diagnostic Criteria
– Cell blood count, indices of inammation,
hemogenic tests, electrolytes, blood glucose,
and immunological.
– Deep swab and tissue sampling for microbio-
logical examination.
– Tissue biopsy.
The objective examination is completed by an
evaluation of the pulses and peripheral pressures
with a portable Doppler, measurement of the
When, in addition to ischemia, we are faced
with infection, the indication for surgery and the
likelihood of amputation increase exponentially.
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To check the level of bacterial load, in the
presence of clinical signs of infection such as
perilesional inammation, pain, or increased
exudate, deep tissue collection should be taken
and sent for microbiological examination.
The culture test result, when positive, is
accompanied by an antibiogram in which the
individual antibiotics tested are indicated according to the degree of sensitivity or resistance.
The bacterial load and minimum inhibitory
concentration (MIC) of the drug should also be
given.
As ulcer infection often leads to osteomyelitis,
evaluation of the underlying bone is critical,
since this pathology does not involve any particular symptomatology that clinically highlights it.
Taking an X-ray is therefore the rst assessment to detect changes in the bone segments.
Usually, the radiograph is positive a few weeks
after the onset of the infectious phase. Cortical
irregularity of the bone underlying an ulcer is
already a suspicious sign. Bone rarefaction or
destruction can reveal signs of osteomyelitis.
They appear when 30–50% of the bone is
destroyed [5].
Since irregularity, rarefaction, and destruction
of the bone may be present in various clinical pictures such as in diabetes, trauma, Charcot pathology, and dysgenesis, and an accurate differential
diagnosis may be necessary.
The only predictive and diagnostic test for
osteomyelitis is bone biopsy.
The most sensitive examination is MRI, which
provides diagnostic accuracy in 80–90% of cases,
as well as precise anatomic denition, useful for
osteomyelitis surgery.
43.2 Dierential Diagnosis
43.2.1 Vascular Ulcers
43.2.1.1 Venous-Based Ulcers
Venous ulceration is dened as an ulceration
related to perforating, saphenous, or deep venous
incompetence, or a combination of these. In these
patients, deep venous reux is usually associated
with calf perforating vein incompetence.
Saphenous vein reux usually accompanies this
condition.
Up to half of the patients presenting with
venous ulcers in the lower extremities have
lesions resulting completely from saphenous vein
incompetence.
Clinical cases with varicose veins and concomitant ankle ulcers often highlight perforating
vein incompetence on clinical examination.
It is common for patients to report a recent or
past local trauma; a previous episode of deep
venous thrombosis is also common but not so
recurring.
Last but not least, the possibility of a congenital thrombophilic disease has to be reported if
present [6].
The patient needs to be asked if they have ever
had calf swelling (as opposed to ankle swelling
which is typical in varicose veins and incompetence of perforating vessels) and, above all, if
there are symptoms suggestive of venous claudication: intense calf pain that starts when the
patient walks for 100 or 200m.
It is fundamental to distinguish this kind of
pain from the dull, deaf, ache that some patients
feel standing for a prolonged period of time
which is common when having venous
incompetence.
Venous ulcers can be found more commonly
on the medial malleolus region, to a lesser extent
on the lateral. They are usually associated with a
less serious saphenous ineffectiveness.
Sometimes these lesions can be found posteriorly or even be circumferential; their depth varies
from 1 to 2mm to an extent till the deep fascia.
It can be helpful to know that usually, they are
much deeper than the varicose and vasculitic
ones.
An inammatory context always goes with
this type of lesion, especially around the ankle,
also with visible narrow supercial veins, pigmentation, and lipodermatosclerosis.
To be noted that patients with venous ulcers
could not have varicose veins.
When the patient comes to the hospital rst, it
is common that these lesions are infected, the
wound could also present little foreign bodies,
wigglers, and slough.
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Once these things are removed and the wound
correctly washed and debrided, the bottom could
be lled with the granulation tissue of pink/red
color.
If the edges are undermined, you should think
about infectious diseases such as tuberculosis or
other chronic infections.
The purpose of the clinical examination is to
not only identify all sites of venous reux or
obstruction but also to exclude the possibility of
arterial inadequacy as a contributing factor.
Patients need to be examined both in laying
and standing positions, signs of obstruction
have to be accessed proximally (iliac and femoral veins) and distally (saphenous and ankle
veins), lipodermatosclerosis needs to be reported
just as signs of pigmentation, skin texture and
thickness, and signs of inammation (rubor,
tumor, calor, dolor). Even abdominal examination and rectal examination are important and
they are mandatory for every patient with a
swollen limb.
Toes and forefoot require attention in order to
detect any sign of ischemia (cianosis and capillary rell).
The arterial pulse of the ankle and feet needs
to be palpated with bare hands or better by a
Doppler ultrasound, such as the ABI index.
As mentioned earlier, a Doppler ultrasound is
useful to detect both the insufciency of the
saphenous veins and the perforator veins.
However, the most effective method to study
the venous system of the lower limb is the Duplex
ultrasound, which should be performed in every
case of detected venous lesions in order to dene
the extent of the problem.
This technique allows the identication of the
incompetent veins and the potential obstruction
of some segments.
If this procedure is not available, venography
can be used as long as you have an expert radiologist in vascular procedures.
43.2.1.2 Arterial-Based Ulcers
Ischemic ulcers may be located on the toes or
forefoot in an area of cyanotic and obviously pregangrenous skin. Another common site is the
heel, especially in bedridden patients. These
ulcers are usually accompanied by severe pain at
rest and are not difcult to diagnose.
Ischemic ulcers may also occur on the dorsum
of the foot or anterior surface of the leg or may
mimic venous ulcers by being located above the
medial or lateral malleolus [7].
The fundus of a typical ischemic ulcer is usually lled with pale yellow purulent exudate and
necrotic debris, often with islands of gangrenous
tissue. The removal of necrotic debris will likely
reveal a deep fascia or tendon, with little or no
granulation tissue. The edges are poorly epithelialized and may be pierced.
A history of ischemic pain at rest is common
in severe cases, while lesser degrees of ischemia
are usually associated with claudication intermittens. Patients are often heavy smokers. Many
patients are elderly and bedridden. This is especially true for heel ulcers, which are usually
described as pressure lesions.
Ischemic ulceration usually occurs in an area
of clear ischemic skin, which may be cyanotic or
pale and shiny [8].
It is necessary to evaluate the pulses: femoral,
popliteal, and ankle. Edema may make the last
one more difcult to perceive, in which case
Doppler ultrasonography should be used. It is not
sufcient to palpate only one ankle pulse, such as
the dorsalis pedis, and then consider if there is
adequate arterial perfusion; it is necessary to palpate both.
The ankle pulse pressure of diabetic patients
with ischemic ulcers may appear normal. This is
due to increased arterial wall stiffness in patients
with diabetes, attributable to calcication, which
makes the measurement of arterial pulse pressure
unreliable. Ischemic ulcers can also result from
small vessel insufciency, particularly in thromboangiitis obliterans (Buerger’s disease) and vasculitis. Ankle pulse pressure may be normal.
Diagnosis depends on the clinical examination of
the capillary rell time of the toe, which is markedly increased with ischemia. Measurement of
the toe pulse pressure by photoplethysmography
(PPG) and a miniature sphygmomanometric cuff
may also be useful. The pressure gradient
between the ankle and toes should not normally
exceed 30mmHg.
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Duplex examination (ECD) of the arteries of
the lower extremities is the most effective method
for determining the presence and distribution of
arterial stenosis and occlusions. This technique
can be used to evaluate vessels of various calibers. The severity of a stenosis can be accurately
assessed by measuring the peak ow velocity at
the stenosis versus the peak ow velocity in the
adjacent non-stenotic vessel. The ratio of these
measurements is called the systolic peak velocity
ratio. The length of the stenosis can also be
assessed. This information is essential in determining whether an arterial lesion has an indication for treatment with an endovascular
technique.
Angiography is usually reserved for the conrmation of ultrasound results before angioplasty
or surgery.
43.2.1.3 Mixed Vascular-Based Ulcers
Ankle ulceration due to a combination of arterial
and venous insufciency is not uncommon, especially in the elderly. Much of the workload in the
management of leg ulcers falls on community
nurses, and modern training courses teach the
skills needed to measure the Winsor index to
detect this problem [9]. This prevents mismanagement of the patient by avoiding the adverse
effects of applying a high-compression bandage
to a severely ischemic limb.
These patients are more likely to provide a
history of varicose veins or previous deep vein
thrombosis than a history suggestive of arterial
insufciency. Objective examination also likely
suggests that the ulcer is purely venous in origin.
There is often no obvious cyanosis or other physical signs indicative of decreased arterial supply.
Accurate examination of the arterial pulses of the
foot is therefore very important in all patients
with a venous ulcer.
Doppler ultrasound measurement of ankle
pulse pressure is essential. Doppler ultrasonography can be used to identify sites of venous incompetence. Comprehensive patient assessment
includes duplex ultrasound evaluation of the arterial and venous systems of the lower extremity to
plan effective treatment in these patients.
43.2.1.4 Vasculitic-Based Ulcers
If there is a clear history of rheumatoid arthritis,
scleroderma, polyarteritis nodosa, or other conditions with a known tendency for vasculitis, the
diagnosis should be straightforward. Difculties
emerge when the patient presents with an apparent venous ulcer and no other obvious manifestations of vasculitis.
Rheumatoid ulcers are usually serpiginous
and shallow. Often multiple, they may involve
the lateral or posterior surfaces of the leg, but
they do not seldom appear in the malleolar
regions and mimic venous ulceration, although
usually without surrounding lipodermatosclerosis. Diligent examination of the hands and other
joints will usually show evidence of rheumatoid
arthritis.
The diagnosis can be conrmed by serologic
testing for the rheumatoid factor. Other systemic
inammatory markers (e.g., erythrocyte sedimentation rate, ESR) may also be used.
Vasculitic ulcers are in general usually present
as small, multiple, and painful. They may be
present in the lower leg or foot.
Specic investigations for vasculitis include
the Rose–Waaler test and latex test for rheumatoid antibodies and tests for autoantibodies.
Anti-DNA double-stranded antibodies are
elevated in SLE (normal: 6–8mg/L).
Anti-neutrophil cytoplasmic antibodies
(ANCA) are elevated in polyarteritis nodosa and
Wegener’s granulomatosis. In many cases of vasculitis, a specic cause cannot be identied.
In these cases, a biopsy of the ulcer edge
including healthy skin and diseased skin may be
useful.
43.2.2 Diabetic Ulcers
Diabetic ulcers can be the result of peripheral
neuropathy, ischemia, or infection, factors that
are common in this disease or could be a combination of all [10].
Speaking of ischemia as a prevalent part, these
lesions could be found on the toes, forefoot, or
heel, especially in bedridden patients.
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Regarding neuropathy which is typical in diabetes, these ulcers are the result of the pressure
on the sole of a Charcot’s foot.
Charcot foot is a condition that causes the
weakening of the bones in the foot that can occur
in people with signicant nerve damage (neuropathy). The bones are weakened enough to fracture, and with continuous pressure and walking
the foot eventually changes shapes.
It is typically associated with diabetes and is a
serious condition that can lead to severe deformity, disability, and even amputation [11, 12].
Charcot foot develops as a result of neuropathy which decreases sensation and the ability to
feel temperature, pain, or trauma. Because of the
diminished sensation, the patient may continue to
walk even with some injuries that makes it worse.
Symptoms of peripheral neuropathy include
hyperesthesia, burning pain, paresthesia, and sensation of cold and heat, which worsen overnight.
Signs consist of reduced pain perception, temperature, and vibration.
Some patients come to the hospital with
wounds but sometimes they are not aware of diabetes; it is fundamental to have blood glucose
and urine examination and if the result is abnormal they should be addressed to the specialist.
After evaluating the location and appearance
of the ulcers, a neurologic examination may not
show any signs of peripheral neuropathy.
Also, venous diseases should be considered
and excluded by examination and ultrasound, as
mentioned before, and even arterial examination
should be done.
The absence or reduction of ankle pulse
should be investigated by arteriography; peripheral ischemia in diabetic patients is often attributed to microangiopathy and it is mandatory to
remember that this kind of patients have a major
incidence of atherosclerosis that could lead to
occlusion of the main limb vessels [13].
others. Many patients with venous or ischemic
ulcers provide a history of precipitating trauma.
It is good medical practice that all patients presenting to the emergency department with abrasions or lacerations of the lower leg be examined
carefully for signs of venous reux or arterial
insufciency. If healing is slow, diabetes should
be ruled out. Simple but necessary investigations
are often omitted, and the initial laceration may
develop into a chronic ulceration. It should be
remembered that abrasions and lacerations of the
lower leg and ankle are always slow to heal, especially in the elderly, even in the presence of normal arteries and veins. A tight bandage or cast
can cause skin necrosis and ulceration, particularly in the elderly and those with minor
ischemia.
Traumatic ulcers can be self-induced. Dummy
ulcers can be quite bizarre in site and appearance
because they are inicted by agents such as elastic bands tied tightly around the calf. The possibility of self-iniction should always be kept in
mind in patients whose ulcers are excessively
slow in healing or repeatedly reoccur.
43.2.4 Pressure Ulcers
Martorell described painful leg ulcers in severely
hypertensive patients. Most of them were located
on the posterior surface of the leg, unlike the typical ischemic ulcers usually found on the dorsum
of the foot or the anterior surface of the leg. It has
been suggested that most, if not all, of these
ulcers, are caused by the embolization of atherosclerotic debris into small dermal vessels.
However, Martorell described a “hyalinosis” of
the tunica intima with stenosis of the arteriolar
lumen.
43.2.5 Edema Ulcers
43.2.3 Post-traumatic Ulcers
Traumatic ulcers can result from any type of
trauma: accidental, self-induced, iatrogenic, and
Ulceration is extremely rare in lymphedema,
whether primary or secondary to lariasis or
malignant lymph node involvement or iatrogenic.
When they occur, these ulcers are usually small,
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indolent, and painless and appear on the anterior
aspect of the ankle or leg.
Patients usually recount a long history of
swelling of the back of the foot and ankle. The
condition is often hereditary, and primary familial lymphedema is known as Milroy’s disease.
Lymphedema is swelling of the limb in the
presence of a normal venous system. This can be
easily established by performing duplex ultrasonography. Failure to demonstrate a venous cause
in a patient with lower extremity edema does not
prove that the patient has lymphedema, but it
greatly limits the range of possible diagnoses.
Doppler ultrasound examination of the ankle
pulses is important in any case of doubt, as ischemic ulceration and lymphedema may coexist.
The most appropriate method to study lymphatic function in order to conrm the diagnosis
is quantitative isotope scintigraphy.
In patients with congestive heart or renal failure, ulceration may occur in the grossly distended
skin of severely edematous legs. Examination
usually shows no evidence of venous insufciency, although some impairment of arterial
supply is likely in these elderly patients. The
ulcers are usually distributed over all surfaces of
the leg; they are shallow and may have a
serpiginous outline. Treatment should be directed
primarily at correcting congestive failure and
reducing edema of the leg. Liver cirrhosis is also
among the edemigenous syndromes, and
declivous edema can also be caused by blockage
of the portal system of another nature.
43.2.6 Infectious-Based Ulcers
43.2.6.1 Tropical Ulcers
These are chronic ulcers of the lower leg or back
of the foot that occur among poor people in tropical countries and are of mixed bacteriology [14].
The most common pathogens are
Pseudomonas aeruginosa, Proteus mirabilis, and
Proteus vulgaris, and also Treponema vincenti
and Bacillus fusiformis. The diagnosis of tropical
ulcer should exclude an ulcer with a specic
underlying cause, such as ischemia, diabetes, or
hemoglobinopathies.
43.2.6.2 Infective Ulcers ofOther
Nature
Leg ulcers due to specic infections are also
more common in tropical countries. Tuberculous
skin ulcers (scrofula) may occur on the legs, but
are more common elsewhere and are characterized by an undermined, irregular, bluish, and
crumbly edge. The ulcers are often multiple, and
the patient usually has signs of pulmonary or
skeletal tuberculosis.
Secondary syphilis is nowadays very rare after
the introduction of antibiotics, but occasionally a
syphilitic gingiva may ulcerate, forming a painless, circular, perforated ulcer with a crust of skin
at the base.
Other specic infections include leprosy,
Guinea worm, caused by the nematode
Dracunculus medinensis, and anthrax
(Woolsorter’s disease), which rarely occur on the
lower limb. Buruli pustule, or Baghdad pustule,
is caused by tropical Leishmania and transmitted
by sand y. Actinomycosis, epidermophytosis,
blastomycosis, moniliasis, and mycetoma
(Madura’s foot) are other infections that can
cause leg ulceration.
43.2.6.3 Osteomyelitis Ulcers
Chronic osteomyelitis of the tibia can be identied by forming a sinus that can mimic a venous
ulceration.
Osteomyelitis can occur anywhere in the leg,
but it is more likely to be mistaken for venous
ulceration when it occurs, as is commonly the
case, in the lower third of the medial surface of
the leg. It is very difcult to distinguish the
appearance of necrotic plaque from venous ulceration. Osteomyelitis of the toes may occur in
association with ischemic ulceration.
Rarely, there may be a history of pulmonary or
abdominal tuberculosis or a history of local
trauma. The radiographic examination normally
shows bone destruction and sequestration formation typical of osteomyelitis.
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43.2.7 Neoplastic Ulcers [15]
43.2.7.1 Squamous Cell Carcinoma
Ulcer
Squamous cell carcinoma can develop in an
inveterate venous ulcer and is known as Marjolin’s
ulcer.
Squamous cell carcinoma should be suspected
in the presence of excessive tissue growth at the
base or edge of the ulcer. Biopsy and histological
examination should be performed urgently.
Squamous cell carcinoma may also develop
per primum on the leg and mimic a venous
ulceration.
43.2.7.2 Basal Cell Carcinoma Ulcer
Basal cell carcinoma may occasionally present
on the leg. The appearance is less likely to mimic
that of venous ulceration than squamous cell carcinoma, and the diagnosis is established by
biopsy.
43.2.7.3 Ulcerated Melanoma
Malignant melanoma is common in the foot and
lower leg, but it is very unlikely to be confused
with venous ulceration.
43.2.7.4 Sarcoma Ulceration
Kaposi’s sarcoma may present with skin ulcerations. The ulcers are usually small and multiple,
similar to vasculitic ulcers. Currently rare, ulcerated Kaposi’s sarcoma is likely to become an
increasing differential diagnosis with the spread
of acquired immunodeciency syndrome (AIDS).
Bone tumors, sarcoma, and osteoclastoma may
also present with ulceration of the leg.
43.2.7.5 Ulcerated Lymphoma
Cutaneous B- and T-cell lymphomas associated
with pyoderma gangrenosum and skin ulcers
have been described. Pyoderma gangrenosum is
also a rare complication of ulcerative colitis or
Crohn’s disease.
43.2.8 Other Ulcers [16]
43.2.8.1 Steroid Ulcers
Patients on long-term steroid treatment may
develop skin ulcers, particularly in the lower
extremities, especially in the elderly. These are
usually broad, shallow, serpiginous ulcers with
poorly epithelialized edges, and the surrounding
skin is thin and fragile. They are often similar to
rheumatoid ulcers and are known to be slow to
heal.
43.2.8.2 Neuropathic Ulcers
Patients with paraplegia or peripheral neuropathy
may develop ulcers. Generally, ulcerations are
misrecognized pressure injuries. Treatment is the
prevention of pressure lesions, and once the
pathogenic noxa is removed ulcer healing occurs
easily by cleaning and standard dressings.
Pressure injuries of various kinds can occur,
including from decubitus medical devices such
as catheters.
43.2.8.3 Dermatitis Ulcers
Dermatitis by contact with stinging substances
can cause existing ulcers not to heal or new ulcers
to develop. This condition is due to sensitivity to
medicated bandages or local antibacterials. The
skin is red and scaly, and the ulcers are usually
shallow with a yellow base, and can appear on
any surface of the body.
The skin around ulcers is more sensitive than
normal skin, and contact dermatitis is a common
complication of ulcer dressings. For this reason,
local steroids, antibiotics, medicated dressings
and bandages (particularly zinc) should be scrupulously avoided and replaced by simpler
alternatives.
Today, cotton bandages and compression
stockings are available and should be prescribed
for patients who are allergic to nylon. Lycra is
commonly used in the manufacture of elastic
stockings, and its use avoids allergies to rubber.
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