Pictorial - Case study

THE CASE 

A 58-year-old woman presented with an ulcer on her lower leg above the ankle. She complained of dull, achy heaviness of her legs and itchiness around the ulcer. She also has varicose veins. On examination there is a dry and brownish coloured area surrounding the ulcer. What is the diagnosis and management?

Diagnosis and management

The diagnosis is venous ulcer with associated eczematoid dermatitis. This condition has a female predominance. The skin around the ulcer is usually lipodystrophic. The ulcer will be painful if infected.

Management includes use of a compression stocking after a Doppler test to confirm normal pressure ratio. Refer once the ulcer has healed if surgery for the varicose veins is required. Advise patients about chronicity, duration of compression treatment and risk of relapse.

POSSIBLE DIFFERENT DIAGNOSES
- Ischaemic ulcer.
- Neuro-ischaemic ulcer.
- Pressure ulcer.
DIFFERENTIAL DIAGNOSIS
- Ischaemic ulcer
- Male predominance.
- Usually multiple and punched out appearance.
- The chronic ischaemic foot is dry and scaly with nail dystrophy.
- Might have claudication.
- Ankle/brachial systolic blood pressure ratio.
- Advice regarding smoking cessation and walking.
- Refer to vascular surgeon.

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