1. Barry Gibson-Smith Anniesland Medical Practice
Leg Ulcers
Barry Gibson-Smith
Anniesland Medical Practice

3. Case 1
A 63year old presents with an 8 week history of a non healing area on her shin. She describes that it started after she bumped her leg on a chair. She has been dressing it herself.
What more from her history do you want to know?

4. History Ulcer – painful, discharge, smell, itchy, change in size,
PMHx –Venous disease, previous DVT,
Arterial disease – IHD, PVD, CVA
Diabetic
Auto-immune – RA, SLE, Inflam BD,
Cancer – general health
Renal disease
Medication – new? immunosuppressants

5. Case1 - A 63year old Established from Hx Venous veins Obesity
Poor mobility
Your working diagnosis is Venous Ulceration. What signs in the leg would support this?

6. Venous ulceration
Signs may include:
Common site is the medial lower aspect of the calf especially over the malleolus.
Varicose veins
Chronic lymphoedema
Pigmentation
Stasis dermatitis (scratched, dry or weeping patches)
Atrophie blanche (scarring with prominent tortuous capillaries)
Lipodermatosclerosis (firm to hard induration)
Multiple ulcers may occur.

8. Case1 - A 63year old
What are you going to do for this lady who you suspect has venous ulceration of her lower leg?

9. Case1 - A 63year old
Ankle Brachial Pressure Index (ABPI) by using a Doppler probe to measure pressure in the arm and the ankle. The normal value 0.92 to 1.3.
Peripheral pulses not reliable
ABPI is less than 0.9, there is likely to be arterial disease. Levels of less than 0.5 indicate severe arterial disease.
Caution in diabetics

10. Case1 - A 63year old Treatment of/with Cellulitis Oedema Leg elevation
Improve mobility
Dermatitis
Compression bandaging
Aspirin and pentoxyphyline
Avoid – sensitisers, antimicrobials, swabbing, fancy dressings

11. Case2 - A 58 year old man Heavy Smoker Hx of IHD
Hx of intermittent claudication
Ulcer for 5 weeks on toe.
Suspect Arterial Ulcer
What signs would support this?

12. Arterial Ulceration Signs-
Usually feet, toes, heels involved and painful
Punched out appearance
Associated with cold white or bluish, shiny feet.
Poor peripheral pulses.
Do ABPI

13. His ABPI is 0.8
What will you do for him?

14. Arterial Ulceration Referral
CVS risk assessment – aspirin, BP, CKD, cholesterol, ?diabetes
Exercise – collateral circulation
Simple dressings
Analgesia
Warning advice - gangrene

15. Case 3
A 47 year old lady with 5 year Hx of Rheumatoid arthritis currently on DMARDs therapy. Develops ulcer on lower leg after simple knock.
What type of ulcers present in this group?

16. Case 3 Ulcers in RA Pyoderma gangrenosum Vasculitis
Risk of arterial ulcers
Cellulitis and associated ulceration
Skin cancer ulcers from use of DMARDs

17. Pyoderma gangrenosum
Vasculitis

18. Case 3 Importance of prompt referral and secondary care involvement
Likely to require high dose steroids
Admission required if progressing rapidly

19. Case 4
An elderly lady presents with a relatively painless ulcer on her lower leg that has been slowly enlarging over several months.
What are your differential diagnoses?

20. Case 4 Basal cell carcinoma Squamous cell carcinoma
Amelanotic melanoma
Requires referral for biopsy and excision
Beware of non-healing ulcers

21. Case 5
A 22year old single mother girl presents with 8 week history of ulcerated area on shin. Lesion is an unusual shape, what diagnosis should be considered and what signs would support it?

22. Case 5- Dermatitis Artefacta
Bizarre shape depending on methods used to injure the skin
Linear or geometric pattern
Lesions at different stages and range from red patches, swelling, blisters, denuded areas, crusts, cuts, burns, and scars.
Lesions emerge quickly (overnight) without any prior symptoms or signs
Accessible sites such as hands, arms, buttocks, lower legs

23. Case 6 What type ulcers can diabetics suffer from?
A 52 year old diabetic patient presents with a painless ulcer on the sole of his foot.
What type ulcers can
diabetics suffer from?

24. Case 6 – Diabetic ulcers Neuropathic ulcers Arterial Venous
Necrobiosis lipoidica
Importance of ABPI and examination
Involvement of diabetic specialist nurses and podiatrist at early stage.

25. Conclusion
Leg ulcers are a common presentation in practice and require a multi-disciplinary approach
Importance of careful history and examination
Importance of ABPI assessment
Importance of biopsy for non healing ulcerated lesions