Barry Gibson-Smith
Anniesland Medical Practice
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A 63year old presents with an 8 week
history of a non healing area on her shin.
She describes that it started after she
bumped her leg on a chair. She has been
dressing it herself.
What more from her history do you want to
know?
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Ulcer – painful, discharge, smell, itchy,
change in size,
PMHx –Venous disease, previous DVT,
Arterial disease – IHD, PVD, CVA
Diabetic
Auto-immune – RA, SLE, Inflam BD,
Cancer – general health
Renal disease
Medication – new? immunosuppressants
Established from Hx
• Venous veins
• Obesity
• Poor mobility
Your working diagnosis is
Venous Ulceration. What signs
in the leg would support this?
Signs may include:
 Common site is the medial lower aspect of the
calf especially over the malleolus.
 Varicose veins
 Chronic lymphoedema
 Pigmentation
 Stasis dermatitis (scratched, dry or weeping
patches)
 Atrophie blanche (scarring with prominent
tortuous capillaries)
 Lipodermatosclerosis (firm to hard induration)
 Multiple ulcers may occur.
What are you going to do
for this lady who you
suspect has venous
ulceration of her lower leg?
•Ankle Brachial Pressure Index
(ABPI) by using a Doppler probe
to measure pressure in the arm
and the ankle. The normal value
0.92 to 1.3.
•Peripheral pulses not reliable
•ABPI is less than 0.9, there is
likely to be arterial disease. Levels
of less than 0.5 indicate severe
arterial disease.
• Caution in diabetics
Treatment of/with
•Cellulitis
•Oedema
•Leg elevation
•Improve mobility
•Dermatitis
•Compression bandaging
•Aspirin and pentoxyphyline
•Avoid – sensitisers,
antimicrobials, swabbing,
fancy dressings
•Heavy Smoker
•Hx of IHD
•Hx of intermittent
claudication
•Ulcer for 5 weeks on
toe.
•Suspect Arterial Ulcer
•What signs would
support this?
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SignsUsually feet, toes, heels involved and painful
Punched out appearance
Associated with cold white or bluish, shiny
feet.
Poor peripheral pulses.
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Do ABPI
His ABPI is 0.8
What will you do for
him?
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Referral
CVS risk assessment – aspirin, BP, CKD,
cholesterol, ?diabetes
Exercise – collateral circulation
Simple dressings
Analgesia
Warning advice - gangrene
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A 47 year old lady with 5 year Hx of
Rheumatoid arthritis currently on DMARDs
therapy. Develops ulcer on lower leg after
simple knock.
What type of ulcers present in this group?
Ulcers in RA
 Pyoderma gangrenosum
 Vasculitis
 Risk of arterial ulcers
 Cellulitis and associated ulceration
 Skin cancer ulcers from use of DMARDs
Pyoderma gangrenosum
Vasculitis
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Importance of prompt referral and secondary
care involvement
Likely to require high dose steroids
Admission required if progressing rapidly
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An elderly lady presents with a relatively
painless ulcer on her lower leg that has been
slowly enlarging over several months.
What are your
differential
diagnoses?
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Basal cell carcinoma
Squamous cell carcinoma
Amelanotic melanoma
Requires referral for biopsy and excision
Beware of non-healing ulcers
A 22year old single mother girl presents with 8
week history of ulcerated area on shin.
Lesion is an unusual shape, what diagnosis
should be considered and what signs would
support it?
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Bizarre shape depending on methods used to
injure the skin
Linear or geometric pattern
Lesions at different stages and range from
red patches, swelling, blisters, denuded
areas, crusts, cuts, burns, and scars.
Lesions emerge quickly (overnight) without
any prior symptoms or signs
Accessible sites such as hands, arms,
buttocks, lower legs
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A 52 year old diabetic patient presents with a
painless ulcer on the sole of his foot.
What type ulcers can
diabetics suffer from?
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Neuropathic ulcers
Arterial
Venous
Necrobiosis lipoidica
Importance of ABPI and examination
Involvement of diabetic specialist nurses and
podiatrist at early stage.
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Leg ulcers are a common presentation in
practice and require a multi-disciplinary
approach
Importance of careful history and
examination
Importance of ABPI assessment
Importance of biopsy for non healing
ulcerated lesions