Leg ulcers

Differential diagnosis

  • Venous stasis/hypertension
  • Arterial insufficiency
  • Neuropathy
  • Vaculitis
  • Neoplastic causes e.g. BCC, SCC
  • Trauma
  • Haematological e.g. leukaemia
  • Infection
  • Metabolic e.g. gout

 

Data gathering

  • History
    • Duration of ulcer
    • Pain
    • Vascular risk factors – DM, MI, PVD, DVT, Varicose veins
    • Intermittent claudication symptoms
    • Previous Treatments
  • Examine
    • Inspect
      • atrophy, hair loss – may suggest poor perfusion and hence arterial ulcer
      • eczematous changes – may be a result of venous eczema
      • infective changes
      • well demarcated – arterial
      • irregular ulcer – venous
    • Location
      • in the “gaiter” area (i.e. area extending from just above the ankle to below the knee and tends to occur on both lateral and medial aspect of the leg)
      • over pressure points – arterial and neuropathic
      • over bony prominence – consider osteomyelitis
    • Measure ulcer
    • Foot pulses
    • Foot temperature
    • Vital signs – BP, HR, temperature, CRT

 

Clinical management 

  • Investigations
    • Bloods – FBC, U+E, LFT, HbA1c, lipids
    • X-ray – if considering osteomyelitis
    • ESR – if considering vasculitis
    • ABPI – if considering arterial cause
  • Treatment
    • Depending on aetiology
      • Non-healing, persistent, worsening ulcer – may require biopsy
      • Simple traumatic ulcer – nurse dressing may be enough
      • Biopsy – if considering malignancy
  • Follow-up / Safety-net
    • Consider district nurse/TVN to dress and monitor
    • Consider dermatology for biopsy
    • Consider vascular surgery for arterial causes