Definition
An ulcer is defined as an area of discontinuity of the surface epithelium. A leg ulcer is an area of ulceration anywhere on the lower limb but usually sited below the knee or on the foot.
Key Points
- Pain suggests ischaemia or infection.
- Neuropathic ulcers occur over points of pressure and trauma.
- Marked worsening of a chronic ulcer suggests malignant change.
- The underlying cause must be treated first or the ulcer will not heal.
- Several precipitating causes may coexist (e.g. diabetes, PVD and neuropathy).
- If underlying varicose veins are present with a venous ulcer they should be treated.
Important Diagnostic Features
Venous Ulcers
- Venous hypertension secondary to DVT or varicose veins: ulceration on the medial side of the leg, above the ankle, any size, shallow with sloping edges, bleeds after minor trauma, weeps readily, associated dermato-liposclerosis.
- Duplex scanning of the veins is indicated to assess the functional status (patency and competence) of the superficial and deep venous systems.
Arterial Ulcers
Occlusive arterial disease: painful ulcers, do not bleed, non-healing, lateral ankle, heel, metatarsal heads, tips of the toes, associated features of ischaemia, e.g. claudication, absent pulses, pallor. Elderly patients may present with ‘blue toe’ syndrome which is caused by microemboli.
Diabetic Ulcers
- Ischaemic: same as arterial ulcers.
- Neuropathic: deep, painless ulcers, plantar aspect of foot or toes, associated with cellulitis, deep tissue abscesses, oedema, warm foot, pulses may be present.
Malignant Ulcers
- Squamous cell carcinoma: may arise de novo or malignant change in a chronic ulcer or burn (Marjolin’s ulcer). Large ulcer, heaped up, everted edges. Lymphadenopathy – highly suspicious.
- Basal cell carcinoma: uncommon on the leg, rolled edges, pearly white.
- Malignant melanoma: lower limb is a common site, consider malignant if increase in size or pigmentation, bleeding, itching or ulceration.
Miscellaneous Ulcers
- Trauma: may be caused by minor trauma. Predisposing factors are poor circulation, malnutrition or steroid treatment.
- Vasculitis (rare): e.g. rheumatoid arthritis, SLE.
- Infections (rare): syphilis, TB, tropical infections.
- Pyoderma gangrenosum: multiple necrotic ulcers over the legs that start as nodules. Seen with ulcerative colitis and Crohn’s disease.
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