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Skin ulcers

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Venous Ulcers

  • Chronic venous insufficiency: Ulcers often located on the medial malleolus, with associated oedema, varicosities, and haemosiderin deposition.
  • Varicose veins: Associated with venous ulcers, particularly in patients with a history of prolonged standing.
  • Post-thrombotic syndrome: History of deep vein thrombosis (DVT) with chronic venous insufficiency and ulceration.
  • Lipodermatosclerosis: Skin changes and fibrosis in the lower legs due to chronic venous hypertension, often leading to ulceration.

Arterial Ulcers

  • Peripheral arterial disease: Ulcers usually located on the toes, feet, or lateral malleolus, often painful, with associated claudication symptoms.
  • Diabetes mellitus: Increases the risk of arterial ulcers due to atherosclerosis and microvascular disease.
  • Buerger’s disease: Thromboangiitis obliterans, a rare condition leading to ischaemic ulcers, typically in smokers.
  • Raynaud’s phenomenon: Severe cases can lead to digital ulcers due to prolonged ischaemia.
  • Vasculitis: Inflammatory conditions like polyarteritis nodosa or giant cell arteritis can cause arterial ulcers.
  • Atherosclerosis: Systemic condition leading to reduced blood flow and subsequent ulceration in the lower limbs.
  • Hypertension: Chronic hypertension can exacerbate atherosclerosis and lead to arterial ulcers.
  • Hyperlipidemia: Contributes to the development of atherosclerosis, increasing the risk of arterial ulcers.
  • Trauma: Minor injuries can result in ulcers in patients with compromised arterial blood flow.
  • Embolism: Acute arterial occlusion leading to ischaemic ulcers, often associated with atrial fibrillation or atherosclerotic plaques.

Neuropathic Ulcers

  • Diabetic neuropathy: Most common cause, typically painless ulcers on pressure points of the foot.
  • Charcot foot: A complication of diabetic neuropathy, leading to deformity and ulceration.
  • Spinal cord injury: Loss of sensation leading to unrecognised trauma and subsequent ulceration.
  • Leprosy: Causes peripheral neuropathy and can lead to neuropathic ulcers, particularly in endemic regions.
  • Syringomyelia: A spinal cord condition leading to sensory loss and ulceration in affected areas.
  • Alcoholic neuropathy: Chronic alcohol use leading to neuropathy and ulceration, particularly on the feet.
  • Autonomic neuropathy: In conditions like diabetes, leading to decreased sweating and dry skin, increasing ulcer risk.
  • Congenital insensitivity to pain: Rare genetic condition leading to painless ulcers due to repeated trauma.

Pressure Ulcers

  • Prolonged immobility: The most common cause, leading to ischaemic necrosis and ulceration in areas of sustained pressure.
  • Spinal cord injury: High risk due to immobility and sensory loss, commonly affecting the sacrum, heels, and ischial tuberosities.
  • Elderly patients: Increased risk due to reduced mobility, malnutrition, and skin atrophy.
  • Malnutrition: Contributes to skin breakdown and delayed healing, increasing the risk of pressure ulcers.
  • Incontinence: Leads to skin maceration and increased susceptibility to pressure ulcers.
  • Sedation or anaesthesia: Reduced mobility and sensation during prolonged procedures increase the risk of pressure ulcers.
  • Friction and shear: Mechanical forces that exacerbate skin breakdown in patients with limited mobility.
  • Vascular insufficiency: In patients with compromised blood flow, increasing susceptibility to pressure ulcers.
  • Comorbidities: Conditions like diabetes or peripheral vascular disease that impair healing and increase ulcer risk.

Malignant Ulcers

  • Marjolin’s ulcer: Squamous cell carcinoma arising in a chronic wound or scar, often aggressive.
  • Basal cell carcinoma: Can ulcerate, presenting as a non-healing ulcer with rolled edges and possible telangiectasia.
  • Melanoma: Advanced cases may ulcerate, with irregular borders and pigmentation.
  • Kaposi’s sarcoma: Vascular tumour associated with HIV, can present as ulcerated plaques or nodules.
  • Cutaneous T-cell lymphoma: Can ulcerate, presenting as non-healing, pruritic patches or plaques.
  • Merkel cell carcinoma: Rare, aggressive tumour that can ulcerate, typically presents as a rapidly growing nodule.
  • Metastatic carcinoma: Secondary skin involvement from internal malignancies can present as ulcerated nodules.
  • Radiation-induced ulcer: Ulceration in areas previously exposed to radiation therapy, potentially leading to secondary malignancy.

Key Points in History 🥼

History of Presenting Complaint

  • Onset: Establish when the ulcer first appeared and whether it has changed in size or character.
  • Pain: Inquire about the nature, severity, and duration of pain associated with the ulcer.
  • Location: Assess the location of the ulcer, as this can provide clues to the underlying aetiology.
  • Progression: Determine if the ulcer has grown, become more painful, or developed new features such as discharge.
  • Symptoms: Ask about any associated symptoms such as fever, weight loss, or systemic signs of infection.
  • Previous ulcers: Document any history of similar ulcers and their outcomes (e.g., healing, recurrence).
  • Trauma: Consider any history of trauma or injury that may have precipitated the ulcer.
  • Medical history: Review for conditions like diabetes, peripheral vascular disease, or immunosuppression that predispose to ulceration.
  • Medication history: Consider medications that may delay healing or predispose to ulcers (e.g., corticosteroids, anticoagulants).
  • Family history: Ask about a family history of skin cancer or other relevant conditions.
  • Occupational history: Consider any occupational exposure to irritants, chemicals, or radiation that may contribute to ulcer formation.
  • Lifestyle factors: Explore smoking, alcohol use, and nutrition, as these can impact wound healing.
  • Sun exposure: Assess the patient’s history of sun exposure, particularly for ulcers in sun-exposed areas, to evaluate skin cancer risk.
  • Cosmetic concerns: Discuss the impact of the ulcer on the patient’s quality of life and any cosmetic concerns.
  • Immunisation status: Particularly important in patients with possible infectious causes of ulcers (e.g., vaccination history for tetanus).
  • Travel history: Consider travel to areas with endemic diseases that could contribute to ulcer formation (e.g., leishmaniasis).
  • Systemic symptoms: Investigate for signs of systemic illness, such as fever, malaise, or unexplained weight loss.
  • Impact on daily life: Assess how the ulcer affects the patient’s daily activities, mobility, and work.

Background

  • Medical history: Review chronic conditions such as diabetes, peripheral arterial disease, venous insufficiency, or autoimmune diseases.
  • Medication history: Consider medications that may impair healing, such as corticosteroids or chemotherapy agents.
  • Surgical history: Ask about any previous surgeries, particularly in the area of the ulcer or in related vascular territories.
  • Family history: Document any family history of chronic wounds, vascular disease, or skin cancer.
  • Social history: Explore lifestyle factors such as smoking, alcohol use, diet, and occupation that may contribute to ulcer risk.
  • Travel history: Consider exposure to infectious diseases in endemic areas that could lead to ulcer formation.
  • Psychosocial factors: Assess the impact of the ulcer on the patient’s mental health, self-esteem, and social interactions.
  • Nutritional status: Poor nutrition, particularly deficiencies in protein, vitamins, and minerals, can impair wound healing.
  • Occupational history: Investigate if the patient’s work involves prolonged standing, exposure to chemicals, or repetitive trauma.
  • Environmental exposures: Explore any contact with chemicals, irritants, or allergens that could contribute to skin ulceration.
  • Sun protection measures: Ask about the use of sun protection, particularly in patients with ulcers in sun-exposed areas.
  • Sexual history: Consider sexually transmitted infections (STIs) that may present with genital ulcers.
  • Immunisation status: Review for tetanus and other relevant vaccinations.
  • Holistic assessment: Consideration of the patient’s overall health, including psychological and social well-being.
  • Psychosocial functioning: Assess how the ulcer affects the patient’s daily life, including mobility, work, and relationships.
  • Safety planning: Discuss safety measures related to ulcer care and management, particularly if surgical intervention is planned.
  • Recent changes: Explore any recent life changes, stressors, or trauma that may have contributed to the onset or worsening of the ulcer.
  • Previous imaging or investigations: Review any prior investigations or imaging studies related to the ulcer.
  • Allergies: Document any allergies, particularly to dressings, adhesives, or topical agents used in ulcer care.
  • Family support: Assess the level of support available to the patient for ulcer care and follow-up.

Possible Investigations 🌡️

Initial Investigations

  • Wound swab: For bacterial culture and sensitivity, especially if infection is suspected.
  • Ankle-brachial pressure index (ABPI): To assess arterial insufficiency in patients with suspected arterial ulcers.
  • Doppler ultrasound: To evaluate venous and arterial flow, particularly in patients with suspected vascular ulcers.
  • Blood tests: FBC, U&E, HbA1c, and inflammatory markers to assess for systemic infection, diabetes control, and overall health.
  • Biopsy: For histological examination if malignancy is suspected or if the ulcer is atypical or non-healing.
  • X-ray: To assess for underlying osteomyelitis in deep or chronic ulcers.
  • MRI: Consider in cases of suspected deep tissue infection or if there is concern about malignancy.
  • CT angiography: To assess arterial supply in patients with suspected peripheral arterial disease and non-healing ulcers.
  • Venography: In patients with suspected venous insufficiency leading to ulceration.
  • Skin patch testing: If allergic contact dermatitis is suspected as a contributing factor to ulcer formation.
  • Serology: For infectious causes, particularly in the context of travel history or systemic symptoms (e.g., syphilis, leishmaniasis).
  • Immunohistochemistry: To assess for specific markers in suspected cases of malignancy.
  • Photographic documentation: For monitoring the progress of the ulcer and response to treatment.
  • Lymph node biopsy: If there is regional lymphadenopathy, particularly in the context of suspected malignancy.
  • Nutritional assessment: To evaluate for deficiencies that may impair wound healing (e.g., protein, vitamin C, zinc).
  • Swab for fungal culture: Particularly in chronic ulcers or those with atypical appearance.
  • Multidisciplinary team (MDT) discussion: In cases of suspected malignancy, involvement of an MDT for treatment planning is crucial.
  • Repeat biopsy: May be necessary if initial biopsy results are inconclusive or if the ulcer changes.
  • Holistic assessment: Consideration of the patient’s overall health and well-being, including psychosocial factors.
  • HIV testing: Consider in patients with unexplained ulcers and risk factors for HIV infection.
  • Referral to dermatology or vascular surgery: For specialised assessment and management, particularly in complex or atypical cases.

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Cardiovascular