Leg Ulcers
Skin ulceration of the lower leg and foot has multiple causes. Venous insufficiency, peripheral arterial disease and diabetes mellitus account for more than 90% of all leg ulcers. 70% are venous, 10% arterial and approximately 10% are of mixed aetiology. A very small minority (2-5%) have other, rarer causes and the assessing practitioner must be aware of the possibility of these other causes and of co-existing diseases, which could affect treatment decisions.
Within Gloucester Hospitals NHS Trust there are a variety of services that deal with lower leg ulceration. The referral pathway for and to Dermatology is as follows:-
(please bear in mind with complex leg ulcers an overlap with the different specialties is required)
Leg Ulcer Service
Venous and mixed aetiology ulceration with mild varicose eczema/associated skin conditions (managed with the skin treatments prescribed).
Venous: A.B.P.I. 0.85 - 1.25 + MEDICAL HISTORY (40mmHg multi – layer compression bandaging)
Mixed: A.B.P.I. 0.65 - 0.85 AND GREATER THAN 1.25 + MEDICAL HISTORY (23mmHg modified compression bandaging
Hyperlink Leg Ulcer Policy
Vascular Department
Arterial ulcers for further investigation and possible revascularisation of occluded vessels in the lower leg.
Arterial: A.B.P.I. ≤0.65 + MEDICAL HISTORY (no compression)
Venous ulcers that are recurrent and/or where there are complicated varicose veins, lipodermatosclerosis and varicose eczema for further investigation and possible vein surgery or foam sclerotherapy by the Vascular team.
Podiatry
Diabetic foot ulcers Policy
Dermatology
Cellulitis
Moderate and complicated varicose eczema and other associated skin conditions such as psoriasis requiring Dermatology specialist input
Neoplasms
- Basal cell carcinoma
- Squameous cell carcinoma
- Marjolin’s ulcer – squameous cell carcinoma developing in a chronic wound
- Malignant melanoma
- Karposi’s sarcoma – malignant tumour arising from blood vessels in the skin, similar in appearance to melanoma
Metabolic disease
- Necrobiosis lipoidica diabeticorum – areas of red/yellow plaques on the lower legs, which can ulcerate. Associated with diabetes and results from infection and fat necrosis
Vasculitis
- Vasculitis is the inflammation of the blood vessels. Inflammation is a normal part of tissue-repair process, but when stimulated inappropriately results in tissue death and necrosis. When vasculitis occurs, the immune complex is activated, affecting the normal free movement of neutrophils through the blood. These adhere to the endothelial lining of the vessels and then release their proteolytic enzymes directly onto the vascular membrane, degrading the tissue and initiating further inflammation. Examples of vasculitis that affect the smaller vessels are:
- Behcet’s disease
- Microscopic polyangitis
- Hypersensitivity vasculitis
Connective Tissue Disorders
- This is a group of disorders with abnormal immunological features such as auto-immune antibodies and immune complex deposition. Their aetiology is unknown or poorly understood. The following contribute significantly to a compromised microcirculation:
- Systemic lupus – a multisystem inflammatory disorder that can result in vasculitis, venous and arterial thrombosis and Raynauds
- Rayneauds – digital vasospasm, divided into three classifications: phenomenon (cold related) syndrome (associated with a disorder), disease (where there is no associated disorder)
- Systemic sclerosis – characterised by chronic inflammatory disorder, fibrosis, degenerative changes and thickening of the skin (scleroderma), which may result in tissue ulceration over bony prominences
- Rheumatoid Arthritis – inflammatory condition of the joints, which can have associated vasculitis episodes
Immunologic causes
- Pyoderma gangrenosum – an acute necrotising cutaneous ulceration sometimes associated with ulcerative colitis or Crohn’s disease. This can occur anywhere on the body but often develops on the lower legs. It is usually diagnosed on appearance by a Dermatologist. Taking a biopsy may aggravate the condition further by creating more inflammation. Management of pyoderma gangrenosum involves specialist attention and treatment with anti-inflammatory drugs
Hypertensive ulcers
- These are painful ulcers on the posterior surface of the lower legs of patients with hypertension. Described by Martorell who suggested that ‘hyalinosis’ of the tunica intima with stenosis of the arteriolar lumen could be seen
Ref:- Martorell F (1950) Hypertensive ulcer of the leg. Angiology. 1:1331-1340
Infections
These include:
- Tuberculosis
- Leprosy
- Tropical ulcers
- Filarial infestation into the lymphatic system causing lymphoedema
Lymphoedema
See under Lymphoedema section for referral guidance