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