Leg Ulcers

Question 1

Causes of leg ulcers?

Answer 1

1. Physical (thorns)
2. Lymphedema
3. Bites
4. Infection: bacterial/fungal/protozoa
5. Pyoderma gangrenosum
6. Necrobiosis lipoidica
7. Haematologic diseases (sickle cell)
8. Vasculitis
9. Vasculopathies
10. Neoplasms
11. Hypercoagulable states
12. Vaso-occlusion
13. Systemic sclerosis
14. Panniculitis
15. Vascular proliferation
16. Drugs
17. Metabolic
18. Genetic
    - common to rare

Question 2

Classification of causes of leg ulcers?

Answer 2

1. venous
2. arterial
3. neuropathic

Question 3

Risk factors of venous ulcers?

Answer 3

1. Obesity
2. Pregnancy
3. Prolonged standing
4. Age
5. Family history

Question 4

Venous flow mechansims?

Answer 4

1. venous valve
2. skeletal muscular pump

Question 5

Pathogenesis of venous insufficiency?

Answer 5

1. Venous pressure↑ →capillary pressure↑ → capillaries dilate →gaps between endothelial cells →leakage of fluid, proteins, leucocytes, red blood cells, fibrine
2. Capillaries irritated →thrombocytes stick to the vessel wall →microthrombi

Question 6

Clinical signs of venous insufficiency?

Answer 6

1. Venulectasias medial side foot
2. Varicose veins
3. Pitting edema
4. Brown discoloration ←haemosiderin deposition ←red blood cells extravasation
5. Stasis dermatitis
6. Lipodermatosclerosis
7. Atrofie blanche
8. Leg ulcer (above medial malleolus)

Question 7

What is venulectasias?

Answer 7

a small dilated, subdermal vein, blue to green in color with a diameter >1mm and <3mm which often develops in the lower extremities due to venous insufficiency
aka reticular veins

Question 8

What are varicose veins?

Answer 8

a dilated often tortuous, subcutaneous vein with a diameter >3mm which can develop in the lower extremities due to venous insufficiency

Question 9

What is pitting edema?

Answer 9

pressing the affected area displaces fluid, leaving a finger shaped depression/pit that disappears within seconds

Question 10

What is non-pitting edema?

Answer 10

not compressible - caused by chronic lymphedema or myxedema

Question 11

What is stasis dermatitis?

Answer 11

an inflammatory skin condition characterized by poorly defined erythematous and eczematous patches and plaques on the lower legs caused by edema due to chronic venous insufficiency
Note: may manifest with pruritus and weeping in acute forms and may result in secondary bacterial infections

Question 12

What is lipodermatosclerosis?

Answer 12

• Localised chronic inflammation→fibrosis of skin and subcutaneous tissue
• Skin indurated, hard, red, hyperpigmented
• Plaque or surrounding entire lower leg
• Inverted champagne bottle shape

Question 13

What is atrofie blanche?

Answer 13

white, coin- to palm sizedatrophicplaquesdue to absentcapillariesin thefibrotictissue

Question 14

What is a venous ulcer?

Answer 14

an ulceration of the skin caused by chronic venous insufficiency
- classically develops superior to the medial malleolus (ankle)
- often associated with skin changes like hyperpigmentation, and unilateral edema
- is usually nos so deep and has an irregular border

Question 15

Unconventional treatment of venous ulcers?

Answer 15

1. maggots
2. leeches

Question 16

Treatment of venous ulcers?

Answer 16

1. Compression
2. Moist environment
   - Occlusion
   - Honey
   - Ointment
3. Skin grafting
   - Full thickness
   - Split skin graft
   - Punch grafts

Question 17

Describe the smells that accompany certain bacterial wound infections?

Answer 17

1. staph aureus - bit yeasty
2. pseudomonas - sweet grape, omelette
3. E. coli - light diarrhea, vomit, bit sweet

Question 18

Treatment of wound infections?

Answer 18

1. Staph aureus
   - Topical antibiotic, antiseptic (povidon-iodine).
   - Flucloxacillin, Amoxicillin/clavulanic acid
2. Pseudomonas
   - Acetic acid 1-3% gauzes bd
3. E. coli
   - Topical

Question 19

Causes of arterial leg ulcers?

Answer 19

1. Atherosclerosis
2. Martorell hypertensive ulcer
3. AV malformation
4. Cholesterol embolism

Question 20

Pathogenesis of arterial ulcers?

Answer 20

Atherosclerosis → blood perfusion↓ →Pain + Tissue necrosis & ulceration

Question 21

Risk factors for arterial ulcers?

Answer 21

1. Cigarette smoking
2. Diabetes mellitus
3. Hypertension
4. Hypercholesterolaemia

Question 22

Clinical signs of arterial ulcers?

Answer 22

1. Leg pain by walking; relief by resting.
2. Leg pain at elevation
3. Cold feet
4. Absent arterial pulses
5. Capillairy refill absent/sluggish
6. Ulcer round, deep, sharply demarcated, fibrous base

Question 23

Treatment of arterial ulcers?

Answer 23

1. Compression
2. Moist environment
3. Skin grafting
   - As other ulcers
4. Pain reduction
5. Stop atherosclerosis progression:
   -exercise; -lifestyle change
6. Arterial dilation: nifedipine
7. Anticoagulant

Question 24

What is atherosclerosis?

Answer 24

The formation of lipid, cholesterol, and/or calcium-laden plaques within the tunica intima of the arterial wall, which can restrict blood flow
Note: Rupture can cause intraluminal thrombosis that results in myocardial infarction, unstable angina, and/or ischemic stroke

Question 25

What is Martorell hypertensive ulcer?

Answer 25

Martorell hypertensive ulcer, also known as hypertensive ischemic leg ulcer or painful purpuric ulcer, is a skin complication associated with chronic hypertension. It typically presents as a painful, non-healing ulcer on the lower extremities, especially the pretibial region

Question 26

Causes of Martorell hypertensive ulcer?

Answer 26

The primary cause of Martorell hypertensive ulcer is chronic hypertension, which leads to vascular changes and reduced blood flow to the affected skin. The condition is often associated with long-standing, poorly controlled hypertension

Question 27

Factors that contribute to the development of the Martorell ulcer?

Answer 27

1. **Arteriosclerosis:** Chronic hypertension can lead to arteriosclerosis, a condition characterized by thickening and hardening of the arterial walls, reducing blood supply to tissues. 2. **Ischemia:** Reduced blood flow results in tissue ischemia, particularly in the pretibial area, leading to the formation of painful ulcers. 3. **Secondary Factors:** Other factors, such as diabetes mellitus or smoking, can exacerbate vascular complications and contribute to the development of Martorell hypertensive ulcer.

Question 28

Clinical features of Martorell hypertensive ulcer?

Answer 28

1. Location - Typically affects the lower extremities, especially the pretibial region. 2. Appearance - Painful purpuric lesions progress to ulcers with irregular borders. 3. Pain - Patients often experience severe pain at the ulcer site. 4. Chronicity - The ulcers are chronic and may be resistant to healing.

Question 29

General management of martorell hypertnsive ulcer?

Answer 29

Early recognition and effective management of Martorell hypertensive ulcer, coupled with optimal blood pressure control, are essential to improve outcomes and prevent complications.

Question 30

Treatment of martorell hypertensive ulcer?

Answer 30

1. Blood Pressure Control - The cornerstone of treatment involves achieving and maintaining optimal blood pressure control. Antihypertensive medications may be prescribed to manage hypertension effectively. 2. Wound Care - Local wound care is essential to prevent infection and promote healing. This may include cleaning the ulcer, applying dressings, and offloading pressure from the affected area. 3. Topical Therapies - Topical treatments, such as wound-healing ointments or dressings, may be used to facilitate the healing process. 4. Pain Management - Pain control is crucial, and analgesics may be prescribed to alleviate the severe pain associated with Martorell hypertensive ulcer. 5. Vascular Assessment - Evaluation of vascular status through imaging studies may be performed to assess blood flow and identify any underlying vascular issues that need to be addressed. 6. Lifestyle Modifications - Patients are often advised to make lifestyle changes, including smoking cessation, maintaining a healthy diet, and regular exercise. 7. Multidisciplinary Approach - Collaboration with specialists such as vascular surgeons, wound care specialists, and dermatologists may be necessary for comprehensive management

Question 31

Causes of neuropathic leg ulcers?

Answer 31

1. leprosy 2. diabetes mellitus

Question 32

Types of Neuropathic ulcers?

Answer 32

1. Sensory neuropathy: loss of sensation →trauma 2. Motor neuropathy: muscle atrophy → deformities →joints: Charcot foot 3. Autonomic neuropathy: - loss of sweating →dry skin →fissures →bacterial entry →infections - blood flow regulation↓ →cutaneous perfusion↓ →ulceration

Question 33

Treatment of neuropathic ulcer?

Answer 33

1. Eradication infection 2. Prevention trauma - inspection, care, therapeutic shoes 3. Wound cleansing, debridement, incl callus 4. Moist wound healing, beware of maceration

Question 34

What is pyoderma gangrenosum?

Answer 34

A neutrophilic dermatosis that manifests with painful, rapidly progressive, erythematous papules and/or pustules that can develop into deep, ulcerated lesions with central necrosis. Associated with inflammatory bowel diseases and autoimmune and hematologic disorders.

Question 35

How does pyoderma gangrenosum start?

Answer 35

nodule, after skin injury (prick, bite)

Question 36

What does pyoderma gangrenosum look like?

Answer 36

- irregular ulcer (moth eaten) - raised, dark-red-purple inflammatory border - undermined -halo of erythema -Base: necrotic

Question 37

Course of pyoderma gangrenosum?

Answer 37

unpredictable, Weeks-months, Slow or rapid

Question 38

Association of pyoderma gangrenosum?

Answer 38

colitis ulcerosa, Crohn, Rheumatoid Arthritis, (SLE, Behçet, e.o.)

Question 39

Treatment of pyoderma gangrenosum?

Answer 39

immunosuppressants (e.g., corticosteroids, cyclosporine A) topical and systemic (prednisone)