The first step toward diagnosis of any leg ulcer is to compile a comprehensive history and assessment of the patient (Table 11.2) [9]. This should include general health status, social and occupational situation, past and current medical history of relevant diseases (such as deep vein thrombosis, diabetes, autoimmune disorders, inflammatory bowel disease, and connective tissue disease), condition of the skin, current vascular status, limb size and shape, and history and status of the ulcer.

The patient should be asked about lower extremity pain, paresthesia, anesthesia, and claudication. It is important to determine the duration of ulceration and whether it is a first episode or recurrent. Pain is a major problem for patients with leg ulcers unless there is a neuropathic component. Lack of pain, therefore, suggests a neuropathic etiology. Patients should also be asked about their mobility.

A typical arterial ulcer is located distally in extremities (toes, heels, and bony prominences of the foot) and usually present with nocturnal rest pain. The ulcer appears “punched out,” with well-demarcated edges and a pale, nongranulating, often necrotic base (Fig. 11.1a), which differentiates it from other types of ulcers (Table 11.3). The surrounding skin may exhibit dusky erythema and may be cool to touch, hairless, thin, and brittle, with a shiny texture. The toe nails thicken and become opaque and may be lost [10]. Gangrene of the extremities may also occur.

Vasculitic ulcers tend to have some characteristics similar to ischemic ulcers, including their location, size, and shallow depth. There are several typical differences, however. Vasculitic ulcers frequently have irregular shapes and borders (Fig. 11.1b). Additionally, the floor of the wound tends to be necrotic with significant vascularity. The surrounding skin is usually hyperemic rather than pale. Vasculitis may also feature other cutaneous manifestations, including palpable purpura, petechiae, and persistent urticaria [1].

A rare condition exists called Martorell ulcer (Fig. 11.1c), seen in patients with prolonged, severe, or suboptimally controlled hypertension [11]. The ulceration is secondary to tissue ischemia caused by increased vascular resistance. The ulcers are usually located at the lower limb, above the ankle region, contain black necrosis and are extremely painful. By definition, the distal arterial pulsations are normal, and the diagnosis is made by histological examination, which shows concentric intima thickening and marked hypertrophy of the media of small-sized and medium-sized arteries, and by exclusion of other conditions that may cause ulceration in this area. The differential diagnosis consists of arteriosclerotic occlusion of small-sized arteries, diabetic angiopathy, vasculitis, thromboembolic occlusion (e.g., in atrial fibrillation), and pyoderma gangrenosum. Treatment consists of reducing hypertension, adequate control of pain, and local wound care [12].

Examination of the arterial system may show a decreased or absent pulse in the dorsalis pedis and posterior tibial arteries. There may be bruits in the proximal leg arteries, indicating the presence of atherosclerosis.

Clinical course of the ulcer can suggest its etiology. Possible considerations to rule out include diabetes; hypertension; hyperlipidemia; coronary artery disease; alcohol and tobacco use; thyroid, pulmonary, renal, neurologic, and rheumatic diseases; and specifically cutaneous factors including cellulitis, trauma, and recent surgery.