Physical or chemical injury
Pressure (decubitus), chemical (corrosive agents) following sclerotherapy, self-inflicted
Squamous cell carcinoma, basal cell carcinoma, melanoma, sarcoma, lymphoma, metastatic cancer
Steroid ulcers, halogens, ergotamine, methotrexate, hydroxyurea, paravasal injection of anticancer drugs as Adriamycin, mitomycin, vaccination ulcer following BCG
Pyoderma gangrenosum, pseudoepitheliomatous hyperplasia, epithelioma, pemphigoid, panniculitis, periarteritis nodosa, erythema induratum, Behcet’s disease, cutaneous discoid and systemic lupus erythematosus, scleroderma, lichen planus, keratosis actinica, contact dermatitis, fat necrosis
Dermatitis, lupus, rheumatoid arthritis, vasculitis, Wegener’s granulomatosis, allergic granulomatosis (Churg-Strauss), Henoch-Schonlein purpura,, erythema induratum Bazin, polyarteritis nodosa, Kawasaki disease
Diabetes mellitus, necrobiosis lipoidica, porphyria cutanea tarda, gout, calciphylaxis, calcinosis cutis, homocysteinuria, prolidase deficiency, hyperoxaluria
Sickle cell anemia, thalassemia, hereditary spherocytosis, glucose-6-phosphate dehydrogenase deficiency, thrombotic thrombocytopenic purpura, granulocytopenia, polycythemia, leukemia, multiple myeloma, cryofibrinogenemia, purpura, hyperglobulinemia
Factor V Leiden, lupus anticoagulant, antiphospholipid syndrome, factor XIII deficiency, antithrombin III deficiency, protein C or S deficiency
Tubercular, erysipelas, gas gangrene, anthrax, diphtheria, herpes, Madura, fungal, amoebiasis, leishmaniasis, leprosy
The ulcers usually present with wound which may or may not be painful associated with edema, burning, itching, and features of inflammation as red, brown discoloration, dry, and scaly skin. Most common ulcer in the leg is venous ulcer, diabetic ulcers, and arterial ulcers. Depending on the location of ulcer, appearance of ulcer, and who is affected can differentiate between the common ulceration of venous, arterial, and diabetic ulcers  (Figs. 6.1, 6.2, 6.3, 6.4, and 6.5).
Diabetic foot ulcer
Leg ulcer are caused by various medical conditions as poor circulation in atherosclerosis, venous insufficiency, diabetes, renal failure, hypertension, lymphoedema, vasculitis, hypercholestremia, smoking, pressure ulcers, malignancies, infections, and sometimes genetic.
For diagnosis of an ulcer, medical history is evaluated, then the ulcer is examined in detail, and various test like X-rays, Doppler, MRIs, CT scan, pus culture, and biopsy may be needed. The treatment of all ulcers begins with careful ulcer care and supportive treatment in form of antibiotics, antiplatelet drugs, etc. .
In examination of an ulcer, edge and floor of ulcer is most important. The edge of the ulcer can determine if it is a healing ulcer or it is a spreading ulcer or it is becoming chronic. Floor also tells about the healing of ulcer or if there is slough. The lymph node must be examined as it may suggest the inflammatory or neoplastic cause.
The ulcers may be classified as spreading ulcer, healing ulcer, or chronic or callous ulcer, and pathologically they can be classified as nonspecific ulcer, specific ulcers, and malignant ulcers. Further the ulcers can be classified as per the grading of involvement (Wagner’s grading): Grade “0” preulcerative or healed ulcer, Grade “I” superficial ulcer, Grade “2” ulcer deeper to subcutaneous tissue exposing soft tissues or the bone, Grade “3” abscess formation underneath osteomyelitis, Grade “4” gangrene of part of tissues/limb/foot, and Grade “5” gangrene of entire one area/foot.
6.2 Thorough History
It is important to find out the cause of any lower extremity ulcer to provide the correct treatment. A thorough physical examination with proper history can give the basic pathological diagnosis in majority of cases, but few patients will require the various investigations to find out the cause. Always try to find out any comorbid illness as diabetes mellitus, hypertension, hypercholesterolemia, autoimmune disease, peripheral vascular disease, atherosclerosis, inflammatory bowel disease, and connective tissue disease must be investigated. Sometimes ulcers may be self-inflicted so a psychiatric evaluation should be done. Any history of deep vein thrombosis, recent surgery, prolonged bed rest, pregnancy, multiple spontaneous abortions, or genetic causes in form of thrombophilia may suggest the cause of ulceration. Patients with venous ulcers may give history of heaviness in limbs especially in the evening. Inquire about history of heavy smoking and drinking, patient’s social and occupational situation as prolonged standing may lead to varicose veins, and subsequent skin ulceration. Patients with higher body mass index are likely to have more ulceration. Find out the history of numbness, paresthesias, burning, or loss of sensation in the feet which may suggest diabetic neuropathic ulcer. Prolonged and poorly controlled diabetes not only causes neuropathies but increases risks of leg infections and impairs wound healing. Also take the history of medications, such as hydroxyurea, which may lead to leg ulceration .
The physical examination must include the systemic examination, limb examination, skin examination, and ulcer examination. The systemic examination must evaluate the heart thoroughly as primary pathology may be in the heart. Also all the systems must be examined as respiratory, cardiac, neurological, abdomen, musculoskeletal examination.
6.2.2 Limb Examination
In the examination of the limb, especially palpate all the pulses up to dorsalis pedis, assess capillary filling time, and also look for signs of venous hypertension. These signs include varicose veins and pigmentation of the skin over the lower leg. The diameter of the limb at various levels must be measured including the normal side also. Mobility should also be assessed at all joints. Leg range of motion at the ankle/knee/hip should also be assessed to distinguish between pain from inflammation and pain from arterial insufficiency. One must examine the sensation of the foot along with motor power.
6.2.3 Skin Examination
Always examine the surrounding tissue. Venous disease may present with staining and pigmented spots especially around the ankle, brawny skin, lipodermatosclerosis, reticular or varicose veins, atrophic blanche (patchy areas of ischemia), telangiectasia, and stasis eczema. In venous ulcers, the surrounding skin may be erythematous with scaling, irregular shaggy borders, and crusting. On the other hand, patients with arterial disease have trophic changes of chronic ischemia, with pale skin which is often hairless, cool, and shiny. Nails may be thickened nail and architecture of the foot may be deformed.
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6.2.4 Ulcer Examination
For having a firm diagnosis, location and pain are the key findings. Venous leg ulcers usually occur in the gaiter region of the lower leg, most often medially, and are superficial with poorly defined margins. The floor is usually red granulation tissue with moderate to high levels of exudate. Exudate levels vary depending on the ulcer size, the presence of leg edema, and the presence or absence of infection. Obese patients with coexisting lymphedema may have more edema and more exudates. Arterial ulcers can occur anywhere on the lower leg and less likely in the gaiter region. Many arterial/ischemic ulcers occur over a bony prominence and have a history of pressure related to the cause. Arterial ulcers have slough and devitalized tissue in the wound floor and less wound exudate. In patients with ulcers on the sole of the foot, the sole should be examined for signs of ascending infection, including proximal tenderness and appearance of pus on proximal compression of the sole. Surrounding calluses are typical of neuropathic ulcerations, and sinus track formation should be explored by probing the wounds. Neuropathic ulcers especially in diabetic patients and other neurological problems occur on the sole of the feet under the metatarsal heads, in the area with the most postural pressure exerted. The other types of ulcers may occur in any part of the lower extremity. The degree of discomfort or pain can give clue to the underlying condition. Arterial ulcers are particularly painful at night, can become severe, and are relieved by dependency and made worse by elevation, even to a horizontal position in bed. Venous ulcers are mildly painful, relieved with elevation, and often get relief from a gentle massaging of the surrounding skin. Ulcers with signs of inflammation with a purple border and extreme pain may be because of vasculitis or underlying connective tissue disorder. They often present with a rapid increase in size, severe pain, and necrotic tissue in the wound base. Lesions that present as blisters such as bullous pemphigoid are related to an autoimmune condition . Table 6.2 shows the differential diagnosis of common ulcers.
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