Fig. 22.1
Upper panel shows an elderly man with chronic painful ulcer over the lower medial ankle with histological findings of hyalinizing vasculitis. Note the surrounding atrophy, whitish discoloration, and telangiectasia characteristic of atrophie blanche. Lower panel shows the lower leg of a young man with ulcerative colitis and pyoderma gangrenosum
Case
An obese, diabetic 65-year-old presents with a chronic, persistent lower leg ulcer. The patient reports minor trauma at the onset of the ulcer. Patient reports two similar lesions, both following trauma but that healed within a few weeks, two years earlier.
The clinical differential diagnosis includes
The history of recurrence precludes ulcerating carcinoma or infection (both being rare causes of leg ulcers). By far, the most common cause of leg ulcers is venous insufficiency, and attempts to confirm or exclude the diagnosis are essential.
venous ulcer
diabetic ulcer,
arterial ulcer,
ulcerating pyoderma gangrenosum (PG) ,
occlusive vasculopathy , and
traumatic/self-induced ulcer .
Clinical Clues
Clinical clues for the possible diagnosis include:
The location of the ulcer
The morphology of the base
The morphology of the border
Severity of pain
The presence of specific findings of arterial or venous insufficiency in the adjacent skin of the lower leg
Location of the Ulcer
Ulcers secondary to venous insufficiency strongly favor the inner or medial ankle overlying the site of the incompetent vein. Arterial ulcers in contrast favor the outer or lateral ankle. Diabetic ulcers favor pressure points of the feet, and are characteristically surrounded by callus tissue due to a walking deformity, secondary to diabetic neuropathy. Ulcers secondary to occlusive vasculopathy , such as anti-phospholipid antibodies or secondary to hyalinizing vasculitis, have no striking preference between the medial or lateral ankle. Also, ulcers secondary to PG do not have site preference over the leg.
Morphology of the Base
Arterial and diabetic ulcers tend to be much deeper and have a punched-out appearance than ulcers due to venous insufficiency and occlusive vasculopathy. All ulcers may have a moist or dry base and a variable degree of granulation tissue based on the duration of the ulcer and its management so far.
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