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Leg Ulcers

An ulcer is an area of discontinuation of the surface epithelium. The 2 vessel types of these are:

  • Venous – Pooling of blood and waste products in skin secondary to venous insufficiency

  • Arterial – Insufficient blood supply to the skin due to peripheral artery disease



In Diabetic Foot, the raised blood sugar leads to ulceration and poor healing. This is more common in those with diabetic neuropathy, in which they’ve lost sensation to their feet. An important complication to look out for here is Osteomyelitis.


Arterial Ulcer

These occur distally, affecting the toes or dorsum of the foot. It presents as:

  • Small, Deep, Pale, Well-defined borders

  • Painful

  • Punched-out appearance


It's typically worse on elevating, and improved by lowering the leg (gravity helps with the circulation).


These ulcers are associated with Peripheral arterial disease (absent pulses, pallor, intermittent claudication).

“A 71-year-old diabetic male smoker with severe peripheral arterial disease presented with a dorsal foot ulceration (2.5 cm X 2.4cm) that had been chronically open for nearly 2 years.” © Jonathan Moore CC BY 3.0 (https://creativecommons.org/licenses/by/3.0/)

Venous Ulcer

These occur in the Gaiter Area (between top of the foot and bottom of calf). It presents as:

  • Large, Superficial, Red, Poorly-defined borders

  • Less painful

  • Irregular appearance


It's typically worse on lowering, and improved by elevating the leg (improves venous return).

“ A 63-year-old female with diabetes and rheumatoid arthritis presented with a chronic venous ulceration (2 cm X 2.6 cm) to the dorsal aspect of the right leg. The wound had been present for over two months despite application of compression therapy and topical agents.” © Jonathan Moore CC BY 3.0 (https://creativecommons.org/licenses/by/3.0/)

Investigations

  • Bloods – FBC, CRP, HbA1C

  • ABPI


Management

Arterial - Same as PAD, with surgical revascularisation


Venous:

  • Tissue viability clinics, Diabetic ulcer services, Clean wound, Debridement, Wound dressing

  • Compression therapy (PAD has to be excluded first)

  • Abx if infection




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