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172 ATYPICAL CAUSES OF LEG ULCERATION
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TABLE3.11
All dressing products in the pack should be in accordance with
local formulary
Cleansing solution (water or saline)– an individual can use tap water if
potable tap water is available
Non- adherent wound contact layer
Secondary dressing (e.g. sterile gauze/adhesive or non- adhesive foam)–
this will depend on exudate levels
Tubular bandage (may assist in securing dressings on a limb)
Wound leaet that includes how to undertake dressing changes and red
ags– when to seek help for, e.g., excessive bleeding, or signs and
symptoms of infection
Information on where to seek help for self- harming
Source: Adapted from Hunt (2017).
Suggested contents ofself- harm rescue pack.
dressings or making them inaccessible to the patient may not be
helpful and may encourage the individual to self- harm on other areas
of the body (Amr etal.2017). Hunt (2017) has suggested providing
the patient with a ‘rescue pack’ containing dressings that are easy for
the individual to use and would assist in empowering the patient to
manage their injuries safely while reducing the potential for infection
(Table3.11).
INFECTIVE CONDITIONS
Lower limb wounds can have various infective causes, including
bacterial, viral, parasitic and fungal, resulting from infective
conditions such as leishmaniasis, ecthyma and Hansen disease.
While historically these types of conditions were associated with
‘tropical’ diseases and/or developing countries, they are increasingly
being seen in developed countries as international travel and
migration increase. As such, any patient who presents with an
unusual ulcer and has recently returned from Asia, Africa, South
America or Australia should consider a possible infective cause.
Diagnosis will be predominantly through wound swabbing and a
wide biopsy for tissue cultures would be indicated if considering an
infective aetiology to a leg ulcer to identify the atypical organism to
be treated (Shelling etal.2010). Occasionally blood cultures may be
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required and a tissue biopsy for histology. Management should
involve a specialist in infectious diseases to guide appropriate
antibiotic or antifungal therapy, treatment strategies and localised
wound care, dependent on the presentation and following wound
assessment.
Ecthyma
Ecthyma is one of the more common infective causes of leg ulcers
and develops from a bacterial skin infection – it is sometimes
associated with deep impetigo. It is mainly caused by group A betahaemolytic Streptococci, but is also often linked to Pseudomonas
aeruginosa (sometimes referred to as ecthyma gangrenosum) and
can also be caused by other common bacteria, such as Staphylococcus
aureus, Escherichia coli and Klebsiella pneumoniae in some cases
(Isoherranen etal.2019). Ecthyma normally occurs when the skin
is in poor condition, for example due to poor hygiene and
malnutrition, or following an insect bite or sting, which is often the
case when seen in a recent international traveller (Isoherranen
etal.2019).
Ecthyma usually begins as a yellowish pustule, typically to the
lower limb, which can quickly ulcerate and develop a necrotic base
with a purple/red border (Isoherranen etal. 2019) (Figure 3.18).
There can be multiple lesions present and they often leave residual
scarring. Ecthyma can be dicult to diagnose as it has numerous
dierential diagnoses, including leishmaniasis, Buruli ulcer,
calciphylaxis, pyoderma gangrenosum and vasculitis (Vaiman
etal.2015).
Leishmaniasis
Cutaneous leishmaniasis (more commonly seen in developed countries) is caused by a parasitic infection transmitted through sandy
bites (Rice2007). Approximately 20% of leishmaniasis lesions occur
on the lower limbs (Ather etal.2006).
Cutaneous leishmaniasis presents as an ulcerated lesion with
raised, reddened edges and a crusty covering (Figure 3.19). Some
lesions will heal spontaneously over a relatively long period of
4–15 months and can lead to severe scarring (Rice2007).
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FIGURE3.18 Ecthyma gangrenosum on the lower leg with multiple,
painful ulcers with areas of necrosis and a purple/red edge.
Source: Kim etal. (2010) / John Wiley & Sons. Reproduced with permission.
FIGURE3.19 Cutaneous leishmaniasis.
Source: Neuber2008 / John Wiley & Sons. Reproduced with permission.
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Hansen Disease/Leprosy
Hansen disease or leprosy is caused by a bacterial organism called
Mycobacterium leprae, transmitted through respiratory droplets. It
mainly aects the skin and peripheral nerves; therefore patients may
present with altered sensation and neuropathic ulcers to the legs
andfeet. Skin changes indicative of Hansen disease are thickened,
cracked skin that is prone to ulceration, with possible papules or
nodules and pale areas of skin that has lost its pigmentation (Walker
and Lockwood2007) (Figure3.20).
Buruli Ulcers
Buruli ulcers are caused by a dierent Mycobacterium to Hansen
disease, Mycobacterium ulcerans, and can be associated with
mosquito bites, animal transmission and poor rural living conditions
(Hartley2014). These ulcers tend to present on the lower limbs as
painless nodules or larger, hardened plaques that slowly develop into
ulcers with undermined borders and necrosis over approximately
FIGURE3.20 Leg ulcer associated with Hansen disease– note the areas of
uneven pigmentation.
Source: Da Costa Nery etal. (2009) / John Wiley & Sons. Reproduced with
permission.
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FIGURE3.21 Buruli ulcer with typical necrosis and undermining edge.
Source: Evans etal. (2003) / John Wiley & Sons. Reproduced with
permission.
four weeks (Franco- Paredes et al. 2018) (Figure 3.21). Extensive
swelling to the whole limb may occur and can be misdiagnosed as
unresolved cellulitis or possibly related to a spider bite (Rice2007).
Treatment can involve surgery and antibiotics, and local wound
management may need to address the debridement of devitalised
tissue and large volumes of thick exudate.
CONCLUSION
This chapter has highlighted some of the conditions that may be
associated with atypical leg ulceration and their key presenting
features and more typical patient histories. While the diagnosis of
atypical leg ulcers will continue to be clinically challenging, an
important focus should remain on making as early a diagnosis of the
underlying aetiology as possible. Continuous reassessment of leg
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Atypical Causes of Leg Ulceration 177
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ulcers that are non- healing and unresponsive to standard therapies
or with abnormal features is vital for detecting the more uncommon
causes and allowing for more timely intervention. The HEIDI
assessment framework can be used to guide the need for reassessment
when wound progression is not as expected.
A multidisciplinary approach is key to the successful diagnosis
and management of atypical leg ulcers. Aim to make prompt and
appropriate referrals to relevant specialities as soon as suspicion is
raised that an uncommon cause may be present.
Local wound care and skincare remain important considerations,
as with other leg ulcer aetiologies, utilising the principles of wound
bed preparation and the TIMES assessment to guide appropriate
dressing selection and timely identication of infection. Pain
assessment using a validated scale is of high importance for patients
with atypical causes of leg ulcers; uncontrolled pain is a common
presenting feature requiring an eective pain management plan and
specialist advice. The judicious use of compression therapy in lower
extremity wounds is considered benecial for all leg wounds.
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