3Case 1A 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?
5Case1 - A 63year old Established from Hx Venous veins Obesity Poor mobilityYour working diagnosis is Venous Ulceration. What signs in the leg would support this?
6Venous ulcerationSigns may include:Common site is the medial lower aspect of the calf especially over the malleolus.Varicose veinsChronic lymphoedemaPigmentationStasis dermatitis (scratched, dry or weeping patches)Atrophie blanche (scarring with prominent tortuous capillaries)Lipodermatosclerosis (firm to hard induration)Multiple ulcers may occur.
8Case1 - A 63year oldWhat are you going to do for this lady who you suspect has venous ulceration of her lower leg?
9Case1 - A 63year oldAnkle 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 reliableABPI 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
10Case1 - A 63year old Treatment of/with Cellulitis Oedema Leg elevation Improve mobilityDermatitisCompression bandagingAspirin and pentoxyphylineAvoid – sensitisers, antimicrobials, swabbing, fancy dressings
11Case2 - A 58 year old man Heavy Smoker Hx of IHD Hx of intermittent claudicationUlcer for 5 weeks on toe.Suspect Arterial UlcerWhat signs would support this?
12Arterial Ulceration Signs- Usually feet, toes, heels involved and painfulPunched out appearanceAssociated with cold white or bluish, shiny feet.Poor peripheral pulses.Do ABPI
18Case 3 Importance of prompt referral and secondary care involvement Likely to require high dose steroidsAdmission required if progressing rapidly
19Case 4An 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?
20Case 4 Basal cell carcinoma Squamous cell carcinoma Amelanotic melanomaRequires referral for biopsy and excisionBeware of non-healing ulcers
21Case 5A 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?
22Case 5- Dermatitis Artefacta Bizarre shape depending on methods used to injure the skinLinear or geometric patternLesions 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 signsAccessible sites such as hands, arms, buttocks, lower legs
23Case 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 candiabetics suffer from?
24Case 6 – Diabetic ulcers Neuropathic ulcers Arterial Venous Necrobiosis lipoidicaImportance of ABPI and examinationInvolvement of diabetic specialist nurses and podiatrist at early stage.
25ConclusionLeg ulcers are a common presentation in practice and require a multi-disciplinary approachImportance of careful history and examinationImportance of ABPI assessmentImportance of biopsy for non healing ulcerated lesions