Differential diagnoses: Lower limb ulceration

Dr Nigel Stollery compares four presentations and offers clues for their diagnosis.

Arterial ulceration


  • Also known as ischaemic ulcers
  • Occurs mainly on lateral side of ankle, bony prominences or distal digits
  • Most common cause is peripheral vascular disease
  • Often has a deep, punched out appearance and is painful
  • Adjacent skin often appears shiny, with absence of hair
  • Peripheral pulses usually absent
  • Doppler test can help diagnosis


  • Can be difficult to treat
  • Hyperbaric oxygen therapy may be helpful
  • Management aimed at treating underlying arterial insufficiency
  • Revascularisation, such as angioplasty, often required

Venous ulceration


  • Also known as stasis or varicose ulcers
  • Major cause of leg ulcers, at up to 90% of cases
  • Occurs mostly on medial side of lower limb, but may extend around whole limb
  • Can be very painful
  • Commonly associated with oedema
  • Chronic venous problems can produce lipodermatosclerosis


  • Treatment focuses on underlying venous insufficiency
  • NICE CG168 advises referral to vascular surgery for ulcers which have not healed after two weeks
  • Compression can be helpful
  • Recurrence is common

Squamous cell carcinoma


  • Should be considered in any chronic non-healing ulcer
  • Can occur in longstanding previously benign ulcer
  • May have thickened or heaped up margin


  • Referral to secondary care can be made under two-week rule
  • Biopsy across ulcer edge useful if squamous cell carcinoma suspected
  • Wide excision and grafting treatment of choice
  • Metastatic potential if not treated

Neuropathic ulcer


  • Most common in diabetics
  • Once ulcer has developed, lower extremity amputation is eight times more likely
  • Nerve damage leads to numbness, after which trauma can cause ulceration
  • Usually painless because of underlying neuropathy


  • Prevention is mainstay
  • Correct footwear and education about footcare are important
  • Early diagnosis of neuropathy important in prevention
  • Specialist input, including debridement, may be required
  • Referral to secondary care diabetic foot clinic can be helpful
  • Dr Stollery is a GP in Kibworth, Leicestershire, and clinical assistant in dermatology at Leicester Royal Infirmary

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