Presentation on theme: "Stasis Dermatitis and Leg Ulcers"— Presentation transcript:
1 Stasis Dermatitis and Leg Ulcers Basic Dermatology CurriculumLast updated June 8, 2011
2 Module InstructionsThe following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.We encourage the learner to read all the hyperlinked information.
3 Goals and ObjectivesThe purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with stasis dermatitis and leg ulcers.By completing this module, the learner will be able to:Recognize the clinical presentation of stasis dermatitisList treatment and preventative measures for stasis dermatitisList the most frequent causes of leg ulcers and describe their presentationsDescribe proper wound care and treatment for leg ulcersDiscuss when to refer a patient with leg ulcers to a specialist
5 Case One: HistoryHPI: Mrs. Paulsen is a 74-year-old woman who presents to the dermatology clinic with leg discoloration for the past three months. The “rash” does not hurt, but occasionally itches. She has not tried any treatment.PMH: diabetes (last hemoglobin A1c was 6.7), hypertension, obesity. No history of atopic dermatitis.Medications: ACE-inhibitor, thiazide diuretic, sulfonylureaAllergies: noneFamily history: noncontributorySocial history: lives with her husband in a nearby townHealth-related behaviors: no tobacco, drug use, or alcoholROS: no leg pain when walking or at rest
6 Case One, Question 1How would you describe her skin exam?
7 Case One, Question 1Erythematous brown hyperpigmented plaque with fine fissuring and scale located above the medial malleolus on the left lower legRight leg with varicositiesNotice the asymmetry? Palpation of the left leg reveals firm skin suggestive of fibrosis
8 Case One, Question 2 What is the most likely diagnosis? Atopic dermatitisCellulitisErysipelasStasis dermatitisTinea corporis
9 Case One, Question 2 Answer: d What is the most likely diagnosis? Atopic dermatitis (adults with AD have a history of childhood AD and a different distribution of skin involvement)Cellulitis (cellulitis occurs more acutely, presents with fever and pain, more erythema, well-demarcated and without pruritus or scale)Erysipelas (a form of cellulitis caused by acute beta-hemolytic group A streptococcal infection of the skin)Stasis dermatitisTinea corporis (would expect sharply marginated, erythematous annular patches with central clearing)
10 Diagnosis: Stasis Dermatitis Stasis dermatitis typically presents with erythema, scale, pruritus (itching), erosions, exudate, and crustUsually located on the lower third of the legs, superior to the medial malleolusCan occur bilaterally or unilaterallyLichenification may developEdema is often present, as well as varicose veins and hemosiderin deposits (pinpoint yellow-brown macules)
13 Venous InsufficiencyStasis dermatitis is a cutaneous marker of venous insufficiency.Normally, venous blood returns from the superficial venous system via perforating veins into the deep venous system.Venous stasis occurs when the valves in the deep or perforating veins become incompetent, causing reflux into the superficial system (venous hypertension).
14 Venous Insufficiency Risk factors for venous insufficiency: Heredity Age (older)FemalePregnancyChronic venous disease is extremely common and is associated with a reduced quality of life secondary to pain, decreased physical function, and mobilityObesityProlonged standingGreater height
15 Venous Insufficiency Early signs of venous insufficiency: Late signs: TendernessEdemaHyperpigmentationLate signs:Lipodermatosclerosis (subcutaneous fat is replaced by fibrosis that eventually impedes venous and lymphatic flow leading to edema above the fibrosis)Venous ulcersScars that appear porcelain white and atrophicTelangiectasiasVaricose veins
17 Lipodermatosclerosis Stasis dermatitis can lead to fat necrosis with the end stage being permanent sclerosis (lipodermatosclerosis) with “inverted champagne bottle” legs as seen herePatients with lipodermatosclerosis may also have acute inflammatory episodes that present with pain and erythema (these episodes can be mistaken for cellulitis)17
19 Elephantiasis Verrucosa Nostra Inflammation of the draining lymphatics (as occurs with cellulitis) results in damage to those vessels resulting in lymphatic insufficiencyThe overlying skin becomes pebbly, hyperkeratotic, and roughUlceration in this setting (with lymphatic and venous insufficiency) is significantly harder to treat and heal19
20 Case One, Question 2Which of the following are complications of venous insufficiency?CellulitisContact dermatitisRecurrent ulcerationVenous thrombosisAll of the above
21 Case One, Question 2 Answer: e Which of the following are complications of venous insufficiency?CellulitisContact dermatitisRecurrent ulcerationVenous thrombosisAll of the above
22 Complications of Venous Insufficiency Recurrent ulcersCellulitis (open wound provides a portal of entry for bacteria)Contact dermatitis (from topical agents applied to stasis dermatitis or ulceration)Venous thrombosis
23 Leg Ulcers and Contact Dermatitis Leg ulcers are subject to sensitization to products used to treat wound healing, leading to contact dermatitis.This is due to the intrinsic allergenic properties of many ointments and wound products, the duration of use, and the disrupted skin barrier.This chronic inflammation and resultant dermatitis lead to poor wound healing and/or recurrence of leg ulcers.
24 Stasis Dermatitis: Treatment It is important to treat both the dermatitis and the underlying venous insufficiencyApplication of super-high and high potency steroids to area of dermatitisElevation (to reduce edema)Compression therapy with leg wrapsChange wraps weekly, or more often if the lesion is very weepy
25 Compression Therapy Works PRIOR TO TREATMENTFOLLOWING TREATMENT
27 Case Two: HistoryHPI: Mr. Baily is a 50-year-old man who presents to his primary care provider with pain in his left leg. He developed a “weeping spot” a few weeks ago, which he tried treating with an over-the-counter antibiotic ointment.PMH: history of a DVT 5 years ago after a transatlantic flight, no longer on anticoagulation, hypertension, type 2 diabetesMedications: thiazide diuretic, ACE-inhibitor, glyburide, metforminAllergies: noneFamily history: father with type 2 diabetes and hypertensionSocial history: lives with wife in an apartment, works in constructionHealth-related behaviors: smokes 1 cigarette/dayROS: as above
28 Case Two, Question 1How would you describe Mr. Baily’s skin exam?
29 Case Two, Question 1Irregularly shaped ulcer located on the medial aspect of the left ankle, erythematous border, exudativeWithout undermining (unable to probe under the edges)Pedal pulses are present, 1+
30 Case Two, Question 2Given the history and exam, what type of ulcer is on Mr. Baily’s left leg?ArterialDiabeticPressureVenous
31 Case Two, Question 2 Answer: d Given the history and exam, what type of ulcer is on Mr. Baily’s left leg?ArterialDiabeticPressureVenous
32 Venous Insufficiency Ulcers Active or healed venous leg ulcers occur in ~ 1% of the general populationThey typically appear as tender, shallow, irregular ulcers with a fibrinous base that are always located below the kneeUsually located on the medial ankle or along the line of the long or short saphenous veinsAccompanied with leg edema, hemosiderin pigmentation, +/- dermatitis of the legPatients may experience symptoms of aching or pain. Discomfort may be relieved by elevation.
33 Leg Ulcers Causes of chronic leg ulcers include: Venous insufficiency 45-60%Arterial insufficiency 10-20%Combination of venous and arterial 10-15%Diabetic 15-25%Malignancy, vasculitis, collagen-vascular diseases, and dermal manifestations of systemic disease may present as ulcers on the lower extremitySmoking and obesity increase the risk for ulcer development and persistence (independent of the underlying cause)
34 Case Two, Question 3Which of the following is the most appropriate next step in evaluating Mr. Baily?Measure the blood pressure in the left arm and left ankleObtain a skin biopsyTreat the ulcer with topical antibioticsUse electrocautery to stop the weeping
35 Case Two, Question 3 Answer: a Which of the following is the most appropriate next step in evaluating Mr. Baily?Measure the blood pressure in the left arm and left ankle (Mr. Baily’s DP pulse was weak suggesting possible co-existent peripheral arterial disease)Obtain a skin biopsy (not necessary unless the diagnosis is unclear or the ulcer does not respond to treatment)Treat the ulcer with topical antibiotics (no, in fact topical antibiotic ointments may lead to a contact dermatitis)Use electrocautery to stop the weeping (trauma may worsen the wound instead of improve it)
36 Ankle/Brachial Index (ABI) Measure the ABI to exclude arterial occlusive diseaseCompression therapy (used to treat venous insufficiency) is contraindicated in patients with significant arterial diseaseThe ABI is the ratio of systolic blood pressure in the ankle to the systolic blood pressure in the brachial arteryNormal: ≥ 0.8< 0.8 = indication of peripheral arterial disease
37 Ankle/Brachial Index (ABI) The ABI is reliable except in diabetes (may be falsely high)An ABI should be performed in all patients with weak peripheral pulses, risk factors for arterial occlusive disease (e.g. smoking, diabetes, hyperlipidemia), and when ulcers are in locations not consistent with venous ulcers
38 Venous Ulcers: Evaluation In addition to assessment of the ulcer, the physical exam of patients with leg ulcers should include the evaluation of peripheral pulses, capillary refill time, peripheral neuropathy, and deep tendon reflexesDiagnosis of venous leg ulcers can be made clinically, however, non-invasive vascular studies such as venous duplex ultrasound and venous rheography can help document the presence and etiology of venous insufficiencyFindings may warrant surgical intervention with endoscopic venous laser ablation, which may prevent further complicationSurgical intervention tends to be more helpful when the venous disease is limited
39 Venous Ulcers: Treatment Address the underlying cause (venous insufficiency) as well as local wound care:Leg elevationKeep the wound moist with a primary dressingTreat dermatitis with topical steroidsCompression therapy (except with an ABI < 0.8)Apply external compression (applied over a primary dressing) with a high compression system such as a multilayer bandage or paste-containing bandage (e.g. Unna’s boot, Duke boot)Treat infection with debridement of necrotic or infected tissues and use systemic antibiotics for infectionMeasure the ulcer at each visit to document improvement
40 Wound Care: The Primary Dressing Keep the wound moist. A moist wound environment promotes healing compared to air exposureChoice of dressings is less important than the program of ulcer treatment outlined on the previous slideSemipermeable dressings that allow oxygen and moisture to pass through (but not water) have made the treatment of leg ulcers easier and more effective
41 Venous Ulcers: Treatment Patient education is crucial in successful treatment:Avoid topical antibiotics in order to prevent sensitization and development of contact dermatitisCleanse the wound with saline. Avoid products like betadine and hydrogen peroxide to prevent skin breakdownAvoid frequent manipulation of the wound. Dressings can be changed as infrequently as once weekly.Once healed, avoid reaccumulation and development of ulcers with regular use of 20-30mmHg compression stockingsPatients with venous ulcers that do not demonstrate response to treatment (reduction in size) after 6 weeks should be referred to dermatology or a wound care clinic
43 Case Three: HistoryHPI: Mr. Lund is a 60-year-old man who presents to his primary care provider with a painful “sore” on his right lateral leg. He reports a history of a “cramping pain” in his calves when walking, but this current pain is more localized to the skin.PMH: hyperlipidemia, hypertension, angina (stable)Medications: statin, thiazide diuretic, sublingual nitroglycerin when needed, aspirinAllergies: NKDAFamily history: father with an MI at age 65, mother with diabetesSocial history: lives with his wife, works in sales, 2 grown childrenHealth-related behavior: smokes ½ pack of cigarettes/day, one glass of wine nightly, no drug useROS: no shortness of breath or recent chest pain
44 How would you describe Mr. Lund’s skin exam? Case Three, Question 1How would you describe Mr. Lund’s skin exam?
45 Case Three, Question 1“Punched out” appearing ulcer with sharply demarcated bordersMinimal exudation and surrounding erythemaDorsalis pedis pulse is absentABI is 0.6
46 Arterial UlcersArterial ulcers are caused by peripheral arterial diseaseOccur on the lower leg, usually over sites of pressure and trauma: pretibial, supramalleolar, and at distant points, such as toes and heelsAppear “punched out,” with well-demarcated edges and a pale baseExudation is minimalAssociated findings of ischemia include loss of hair on feet and lower legs, shiny atrophic skin
47 Arterial UlcersPulses (dorsalis pedis and posterior tibial) may be diminished or absentStasis pigmentation and lipodermatosclerosis are absent (unless patient also has venous disease)Associated with intermittent claudication and painAs disease progresses, pain and claudication may occur at restUnlike venous ulcers, leg pain often does not diminish when the leg is elevated
48 Case Three, Question 2Which of the following recommendations should take priority?Encourage him to ambulateEncourage him to stop smokingMake sure his blood pressure and hyperlipidemia are under good controlRefer to a vascular surgeon
49 Case Three, Question 2 Answer: d Which of the following recommendations should take priority?Encourage him to ambulateEncourage him to stop smokingMake sure his blood pressure and hyperlipidemia are under good controlRefer to a vascular surgeon (although all the answer choices are correct, the main goal of therapy is the re-establishment of adequate arterial supply)
50 Arterial Ulcers: Treatment Refer to a vascular surgeon for restoration of arterial blood flow with percutaneous or surgical arterial reconstructionPatients should stop smoking, optimize control of diabetes, hypertension, and hyperlipidemiaWeight loss and exercise are also helpfulAll types of ulcers require proper wound care as outlined above in venous ulcer treatment
52 Case Four: HistoryHPI: Mr. Stricklin is a 46-year-old man who presents to his primary care provider with lesions on the bottom of his foot. He noticed these lesions a few months ago when he was changing his socks at the gym. He reports keeping them clean with hydrogen peroxide.PMH: type 1 diabetes x 25 years, hernia repair 20 years agoMedications: insulin (glargine and regular)Allergies: noneFamily history: noncontributorySocial history: lives alone, works as a realtorHealth-related behaviors: no tobacco, alcohol, or dug useROS: no fevers, sweats or chills
53 Case Four: Skin ExamCallus has been debrided, revealing ulcers on the plantar footAble to undermine the ulcers with a metal probe, unable to track the ulcer to the bone
54 Diabetic (Neuropathic) Foot Ulcers Peripheral neuropathy, pressure, and trauma play prominent roles in the development of diabetic ulcersUsually located on the plantar surface under the metatarsal heads or on the toesRepetitive mechanical forces lead to callus, which is the most important preulcerative lesion in the neuropathic foot
55 Diabetic (Neuropathic) Foot Ulcers Lifetime risk of a person with diabetes developing a foot ulcer is as high as 25%Risk factors for foot ulcers include:Cigarette smokingPast foot ulcer historyPeripheral vascular dzPrevious amputationPoor glycemic controlPeripheral neuropathyDiabetic nephropathyVisual impairment
56 Diabetic Foot Ulcer: Evaluation and Treatment Diabetic patients with foot ulcers are often best managed in a multidisciplinary setting (podiatrists, endocrinologists, dietician)Remove the callous surrounding the ulcer (together with slough and non-viable tissue)Probe the ulcer to reveal sinus extending to bone or undermining of the edges where the probe can be passed from the ulcer underneath surrounding intact skinOrder an imaging study if concerned about bone involvementPatients with suspected osteomyelitis should be admitted to the hospital for evaluation and treatment
57 Diabetic Foot Ulcer: Evaluation and Treatment Use dressings to maintain a moist environmentApplication of platelet-derived growth factor gel has been shown to improve wound healing in diabetic foot ulcersProtect the ulcer from excessive pressureRedistribute plantar pressures with casting or special shoes (a podiatrist with expertise in the management of the diabetic foot is extremely helpful)Restrict weight bearing of the involved extremity
58 Case Four, Question 1Which of the following statements about Mr. Stricklin is likely to be true?He has diabetic neuropathyHe should continue to use hydrogen peroxide to keep his lesions cleanHe should wear open-toed shoesNone of the above
59 Case Four, Question 1 Answer: a Which of the following statements about Mr. Stricklin is likely to be true?He has diabetic neuropathy (diabetic neuropathy can cause a loss of protective pain sensation as well as motor dysfunction)He should continue to use hydrogen peroxide to keep his lesions clean (not true. Hydrogen peroxide interferes with wound healing)He should wear open-toed shoes (diabetic patients should avoid open-toed and pointed shoes)None of the above
60 Diabetic Foot Ulcers: Prevention Education about ulcer prevention should be provided for all diabetic patientsGlycemic control is essential in preventing diabetes associated complications, including peripheral neuropathyPatients should receive annual foot examinations, with a clinical assessment for peripheral vascular disease and monofilament test for peripheral neuropathyPatients should examine their own feet regularlyIf present, treat tinea pedis (to prevent the associated skin barrier disruption)Encourage smoking cessation (risk factor for vascular disease and neuropathy)Optimize treatment of hypertension, hyperlipidemia, and obesity
62 Case Five: HistoryHPI: Mrs. Dellinger is a 50-year-old woman who presents to her primary medical provider with a 4-day history of new, very painful lesions on her hand and thigh. She initially thought these lesions were bug bites, but they now appear to be expanding and look more like ulcers.PMH: inflammatory bowel disease (well-controlled)Medications: sulfasalazine daily, multivitamin, fish oilAllergies: no known drug allergiesFamily history: brother with ulcerative colitisSocial history: lives with husband and 20-year-old daughter, works full-time as a high school teacherHealth-related behaviors: reports no alcohol, tobacco, or drug useROS: no fevers, joint pains, abdominal pain or diarrhea
63 Case Five, Question 1How would you describe the following skin findings?
64 Case Five, Question 1Ulcer with undermined (able to probe underneath) violaceous border, exudative
65 Case Five, Question 2Given the history and exam findings, Mrs. Dellinger’s primary care provider is concerned about pyoderma gangrenosum (PG) and made an urgent referral to the dermatology clinic.Which of the following is true about PG?A biopsy of PG is diagnosticDebridement of the ulcer will help the healing processPG is a slow processPG is often mistaken as a spider bitePG is painless
66 Case Five, Question 2 Answer: d Which of the following is true about PG?A biopsy of PG is diagnostic (Not true. There are no specific histological features on skin biopsy)Debridement of the ulcer ill help the healing process (No! In fact, PG is triggered and made worse by trauma – a process called pathergy)PG is a slow process (Not true. PG rapidly progresses)PG is often mistaken as a spider bite (True! In fact, we recommend you consider PG or MRSA when the diagnosis of a brown recluse spider bite is at the top of your differential)PG is painless (Not true. PG is often very painful)
67 Pyoderma Gangrenosum (PG) PG is an inflammatory ulcerative process mediated by an influx of neutrophils into the dermisBegins as a small pustule which breaks down and rapidly expands forming an ulcer with an undermined violaceous borderSatellite ulcerations may merge with the central larger ulcerRapid progression (days to weeks)Can occur anywhere on the body (most frequently occurs on the lower extremities)Can be very painful
68 Pyoderma GangrenosumPG is triggered by trauma (pathergy), including insect bites, surgical debridement, attempts to graftPG is often misdiagnosed as a brown recluse spider biteThough the majority of patients with PG do not have an underlying condition, PG is often associated with a wide range of other pathologies that the patient should be evaluated forInflammatory bowel disease (1.5%-5% of patients get PG), rheumatoid arthritis, hematologic dyscrasias, malignancy1/3 of PG patients have arthritis: seronegative, asymmetric, monoarticular, large joint
69 Note the undermined violaceous border Another Example of PGNote the undermined violaceous border
70 PG: Evaluation and Treatment PG should be considered a dermatologic emergency and an urgent referral to a dermatologist should be consideredThe diagnosis of PG is one of exclusion; there are no specific histological or clinical featuresAlthough non-diagnostic, a skin biopsy is often performed to exclude other conditionsTreatment of the underlying disease may not help PG (often doesn’t)Topical therapy: Superpotent steroids, topical tacrolimusSystemic therapy: Systemic steroids, cyclosporine, tacrolimus, cellcept, thalidomide, TNF-inhibitors
71 Take Home Points Chart Characteristic Arterial Ulcer Venous Ulcer Diabetic UlcerLocationAnkle, toes, and heelsMedial region of the lower legOn soles, over bony prominencesAppearanceIrregular margin, punched out edges, little exudateIrregular margin, sloping edges, pink base, usually exudativeOverlying callus, undermined, red, often deep and infectedSkin temperatureCold and dryWarmWarm and dryPainPresent, may be severeMild-moderate, unless infected or with significant edemaMay be absentArterial pulsesDiminished or absentPresentPresent or absentSensationVariableLoss of sensation, reflexes, and vibration senseSkin changesShiny and taut, edema not commonErythema, edema, hyperpigmentation, lipodermatosclerosisShiny, taut, or doughyTreatmentRefer to vascular surgeon, wound careCompression is mainstay, wound careRemove callus, off-load pressure
72 Take Home PointsStasis dermatitis is a cutaneous marker for venous insufficiencyThe most common types of leg ulcers include venous, arterial, combined (venous and arterial), and diabeticDiagnosis of leg ulcers may be made clinically, but evaluation with non-invasive vascular imaging and the ABI will often guide treatmentTreatment of venous leg ulcers includes leg elevation, compression, and wound carePatients with arterial ulcers should be referred to a vascular surgeon for restoration of arterial blood flow
73 Take Home PointsA callus is the most important preulcerative lesion in the diabetic footOsteomyelitis should be considered in patients presenting with diabetic foot ulcersEducation about ulcer prevention should be provided to all diabetic patientsThe diagnosis of PG should be considered in the rapidly expanding painful ulceration of the lower legPG is a dermatologic emergency and patients should be referred to a dermatologist
74 AcknowledgementsThis module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup fromPrimary authors: Sarah D. Cipriano, MD, MPH; Timothy G. Berger, MD, FAAD.Peer reviewers: Theodora Moro, MD; Patrick McCleskey, MD, FAAD; Peter A. Lio, MD, FAAD.Revisions and editing: Sarah D. Cipriano, MD, MPH; John Trinidad.Last revised June 2011.
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