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Lymphatic Research and Biology 12 (2):
CHAPTER
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3
Atypical Causes ofLeg
Ulceration
SARAH BRADBURY AND KIRSTEN MAHONEY
ost leg ulcers will typically come under the diagnosis of either
M
venous, arterial, mixed aetiology (venous and arterial),
lymphoedema or diabetic foot ulcers (National Wound Care Strategy
Programme [NWCSP]2023). A small proportion of lower leg wounds,
however, may be caused by less common aetiologies that are often
associated with, or caused by, inammation, infection, malignancy,
chronic illness or genetic disorders (Isoherranen etal.2019). These
types of leg ulcers are usually referred to as atypical wounds. One of
the most important aspects to consider when treating a patient with
an atypical ulcer is the correct identication and management of the
underlying systemic condition that is contributing to or causing the
ulceration (Falanga2007).
The diagnosis of an atypical leg ulcer is often challenging in
clinical practice, and treatment regimens can be complex, requiring a multidisciplinary approach from specialist teams that may
include dermatology, rheumatology, vascular, haematology, oncology and psychology. This list is not exhaustive and is dependent on
the diagnosis and local availability of services. It is often the signicant delay in diagnosis that contributes to inappropriate
Lower Limb and Leg Ulcer Assessment and Management, First Edition.
Edited by Aby Mitchell, Georgina Ritchie, and Alison Hopkins.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
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Atypical Causes of Leg Ulceration 107
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management and higher mortality rates for this cohort of patients
(Isoherranen etal.2019).
Early identication and referral to an appropriate specialist team
for a patient suspected of having an atypical leg ulcer are essential and
can assist in preventing unnecessary wound deterioration, managing
the symptoms eectively, decreasing the risk of complications and
improving the quality of life for the individual. Healthcare professionals (HCPs) therefore are required to have the appropriate skills and
knowledge to undertake a structured holistic wound assessment
(see Chapter 5) to assist in identifying the aetiology of the wound
and potential barriers that may impact the healing process
(Wounds UK2018).
The HEIDI (History, Examination, Investigations, Diagnosis,
Interventions) framework oers a unied and systematic approach
to wound assessment that is particularly useful for identifying atypical aetiologies (Harding etal.2007). It encapsulates identication of
the co- morbidities, environmental and local wound factors that contribute to wound complexity and are essential criteria for making a
denitive diagnosis and an eective multidisciplinary management plan.
Factors that may lead to the suspicion of an atypical leg ulcer
diagnosis include (Isoherranen etal.2019):
Abnormal presentation/location.
High levels of pain for the size of the wound.
Non- healing after 4–12 weeks of evidence- based care.
It is important for HCPs to be aware of these factors to aid in the
diagnosis, treatment and management of atypical ulcers.
INFLAMMATORY/AUTOIMMUNE DISORDERS
Pyoderma Gangrenosum
Pyoderma gangrenosum (PG) is a rare autoinammatory skin condition
characterised by neutrophilic inltration of the dermis (neutrophilic
dermatosis). Although the condition can occur on any part of the body
and at any age, it is more commonly found in the lower limb and in
women over the age of 50 (Binus etal.2011). The exact aetiology and
108 ATYPICAL CAUSES OF LEG ULCERATION
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pathophysiology of the disease are unknown and possibly multifactorial.
However, it has been recognised that there are characteristically
abnormal neutrophils and high levels of inammatory mediators
present within the wound environment (George etal.2019).
There are ve main subtypes of PG: classic ulcerative, bullous,
vegetative, pustular and peristomal. The most common subtype that
is usually seen on the lower leg is classic ulcerative PG, which
accounts for 85% of cases (Fletcher etal.2019). Classic ulcerative PG
is most commonly seen on the lower extremities, although it occasionally appears on the trunk, abdomen and genital area.
History
The dermatological presentation of PG often manifests as a result of
systemic inammatory disease and can be associated with other inammatory or haematological conditions, such as rheumatoid arthritis
(RA), inammatory bowel disease or leukaemia, or pro- inammatory
genetic syndromes (e.g. PAPA – pyogenic arthritis, PG and acne; or
PASH– PG, acne and suppurative hidradenitis) (Fletcher etal.2019;
Patel and Piguet2022). It has been suggested that 50% of patients with
PG have underlying associated diseases (George etal.2019), therefore
consideration of associated co- morbidities should be an essential part
of history taking and may assist in establishing a diagnosis.
Patient history may indicate that the wound started as an
erythematous nodule or pustule, which developed quickly into a
painful deep ulcer within days. PG ulcers also sometimes occur and
deteriorate rapidly following trauma, biopsy or surgery – this is
known as pathergy (George etal.2019).
PG ulcers typically are extremely painful; assessment of pain
levels should be conducted at each dressing change and following the
commencement of any treatment using an appropriate validated
pain assessment tool, such as the Visual Analogue Scale (VAS) (ScottThomas etal.2017).
Examination
Individuals may present with up to three ulcers (Fletcher etal.2019).
Features that are commonly seen in PG are a purple discoloration to
the edge of the wound, known as a violaceous border (Figure3.1),
and the surrounding skin may have the appearance of ‘wrinkled
Atypical Causes of Leg Ulceration 109
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FIGURE3.1 Typical presentation of PG with violaceous (purple border).
Source: Used with permission from Cardi & Vale University Health Board.
FIGURE3.2 Cribriform scar.
Source: Used with permission from Cardi & Vale University Health Board.
paper’ over the sites of previously healed ulcers, which is referred to
as cribriform scarring (Figure3.2) (Fletcher etal.2019). Examination
of the lower limb should follow the principles of TIMES as outlined
in Chapter5 (see Table3.1).
110 ATYPICAL CAUSES OF LEG ULCERATION
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TABLE3.1
Tissue within
the wound bed
Infection/
inammation
Moisture balance Exudate levels may be variable and could range from
Edge The appearance of the wound edge is often seen as
Surrounding skin Previous scars from PG often have the appearance of
Source: Adapted from George etal. (2019) and Rice (2007).
Typical clinical presentation ofpyoderma gangrenosum (PG).
The wound bed may be variable. There may be friable
granulation and necrosis, and soft slough may also
be evident
Inamed peri-
be present
minimal to moderate depending on the amount of
non- viable tissue, the presence of infection and the
amount of oedema present in the lower limb
darkpurple in colour (typically referred to as a
violaceous border). The edge may also appear
raggedor scalloped
‘wrinkled paper’ (cribriform) (Figure3.2)
wound skin. Secondary infection may
Investigations
There is currently no clinical criterion or laboratory test to conrm
the presence of PG (George etal.2019) and it is often described as a
diagnosis by exclusion (Isoherranen et al.2019). A biopsy of the
active ulcer edge may be required to exclude other possible causes
such as malignancy or infection. However, one of the classic
manifestations of PG is the exaggerated response to trauma or
minor skin injury (known as pathergy), therefore biopsies are
undertaken with caution as they may cause deterioration and
enlargement of the ulcer and worsening of symptoms (George
et al. 2019). With PG, typically biopsies of the ulcer edge will
demonstrate inltration of neutrophils (Maverakis et al. 2018).
Inltration of neutrophils has an important role in inammation
and can contribute to tissue damage, it is often present in
autoinammatory skin conditions as a response to underlying
systemic disease. To exclude arterial disease, measurement of an
ankle brachial pressure index (ABPI) should be undertaken as part
of the lower limb assessment (Todhunter2019). It may however not
be possible to undertake an ABPI measurement in patients with PG
Atypical Causes of Leg Ulceration 111
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who are experiencing uncontrolled pain or if the limb size is outside
the ankle cu range (Wounds UK 2019). Toe pressures, or a toe
brachial pressure index (TBPI), should therefore be considered if
the ankle cu cannot be applied or if calcication of the arteries is
suspected (Wounds UK2016).
Diagnosis
There are currently no national or international criteria for the
diagnosis of PG and not all PG ulcers present with the characteristic
violaceous border or cribriform scarring, which can make diagnosis
more challenging in clinical practice (Fletcher et al. 2019).
Misdiagnosis, however, can lead to inappropriate treatments such as
debridement, which potentially could contribute to a signicant
deterioration in the ulcer due to pathergy (George etal.2019).
A diagnosis is typically made using clinical indicators such as
ulcer presentation, and clinical history and exclusion of other possible causes such as malignancy and infection (Fletcher et al.2019).
Maverakis etal. (2018) proposed a diagnostic tool (Table3.2) to assist
in reducing the probability of an inaccurate diagnosis. Within the
diagnostic tool, patients would need to display one major criterion
and four minor criteria.
TABLE3.2
Major criteria Biopsy of ulcer edge that shows neutrophil inltrate
Minor criteria Exclusion of infection
Source: Adapted from Maverakis etal. (2018) and George etal. (2019).
Diagnostic tool forpyoderma gangrenosum.
Pathergy
History of inammatory bowel disease or
inammatory arthritis
Papule or pustule that ulcerates within four days of
appearance
Peripheral erythema, undermining border and pain at the
ulcer site
Multiple ulcerations, at least one on the lower leg
Cribriform scarring
Responds to treatment with immunosuppressive
medications
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