Differential Diagnosis Of Leg Ulcers Research Articles

The Differential Diagnosis of Leg Ulcers.

Chronic wounds on the leg (below the knee) are called leg ulcers. They have many causes, and thus patients with leg ulcers are treated by many different kinds of medical specialist. Appproximately 80% of sufferers have chronic venous insufficiency (CVI) and/or peripheral arterial occlusive disease (PAOD). Knowledge of the relevant differential diagnoses is important for appropriate treatment, particularly for patients with atypical findings or an intractable course. This article is based on publications retrieved by a selective search in PubMed, including current guidelines and expert recommendations. The diagnostic evaluation of a leg ulcer can be structured according to the ABCDE rule. This involves individualized, targeted history-taking (anamnesis); bacteriological testing; clinical examination; ancillary testing, particularly for perfusion (defective vascular system); and extras, such as biopsies. Specifically, we present in this article the main aspects of the complex diagnostic evaluation of venous leg ulcers, arterial leg ulcers, vasculitis, vasculopathy, calciphylaxis, pyoderma gangrenosum, necrobiosis lipoidica, ecthyma, and squamous cell carcinoma. There remain many unsolved problems, including interactions between the various areas of clinical treatment and the relative paucity of relevant high-quality research. A timely differential-diagnostic evaluation for the many diseases that can cause leg ulcers, which require treatment from representatives of many different medical specialties and health professions, is a prerequisite for their effective individualized treatment.

Occlusive cutaneous vasculopathies as cause of chronic ulcers.

The term occluding vasculopathies covers a large number of different conditions. These often manifest as skin ulcers. Occluding vasculopathies should be considered in the differential diagnosis of leg ulcers. The term "occlusive vasculopathies" encompasses pathophysiologically related entities that share structural or thrombotic obliteration of small cutaneous vessels. In this article, we will focus on livedoid vasculopathy with and without antiphospholipid syndrome and calciphylaxis with differentiation from hypertonic leg ulcer as the most relevant differential diagnoses of leg ulcer. The term also includes vascular occlusion, for example due to oxalate or cholesterol embolism, and septic vasculopathy. This often leads to acral ulceration and is therefore not a differential diagnosis with classic leg ulcers. It will not be discussed in this article. Occlusive vasculopathy may be suspected in the presence of the typical livedo racemosa or (non-inflammatory) retiform purpura as a sign of reduced cutaneous perfusion in the wound area. Inflammatory dermatoses, especially vasculitides, must be differentiated. This is achieved by histopathological evaluation of a tissue sample of sufficient size and depth taken at the appropriate time. In addition, specific laboratory parameters, particularly coagulation parameters, can support the diagnosis.

Leg Ulcers: Diagnosis and Management (3rd edn)

The title, Leg Ulcers: Diagnosis and Management, gives the impression that this text book has been restricted to the subject of leg ulcers. However, one soon discovers that it is a comprehensive text book of lower limb venous diseases. Leg ulcers, particularly those of venous aetiology, constitute a major health problem in most Western countries. A significant proportion of the venous leg ulcer patients are relatively young, resulting in economic losses not only from the cost of treatment but also from the wastage of productive man-hours. As highlighted in the text book, the principal health personnel who manage venous leg ulcers vary between countries. In the UK, for example, the majority are initially seen and managed by nurses in community leg ulcer centres. This, notwithstanding the high profile given to venous diseases in general and leg ulcers in particular by the editors, is highly commendable since for most vascular units venous disease would contribute to at least 30% of their workload. A detailed examination of normal anatomy and physiology of lower limb veins and a thorough discussion of pathology, pathological anatomy, pathophysiology, epidemiology and clinical presentation of all aspects of lower limb venous diseases have been systematically reviewed. Venous leg ulcers have been didactically presented with the specialist in mind. Extensive discussion of conventional and the more controversial views on pathophysiology have been appropriately discussed in a balanced format without the authors' personal bias influencing the quality of materials presented. The basis for the accepted methods of investigation and treatment of venous leg ulcers, including compression, therapy and surgery are well presented. Unproven methods of treatment like pharmacotherapy, topical treatment and more modern methods including foam sclerotherapy, echosclerotherapy and endovenous laser treatment have also been adequately covered. There is also a very good chapter on ‘The Differential Diagnosis of Leg Ulcers’. The text is illustrated using excellent line diagrams, black-and-white as well as colour photographs. Each chapter has been very well researched with a comprehensive list of references. Perhaps my only criticisms of the text book are the several instances of repetition and a few typographical errors. On the whole, however, it is a good specialist text book of lower limb venous diseases which any vascular surgeon with a special interest in this field would find quite useful.

Differential diagnosis of leg ulcers

Leg and foot ulcers are symptoms of very different diseases. The aim of this paper is to demonstrate the differential diagnosis of leg ulcers. The majority of leg ulcers occur in the lower leg or foot. In non-venous ulcers the localization in the foot area is more frequent. The most frequent underlying disease is chronic venous disease. In 354 leg ulcers, Koerber found 75.25% venous leg ulcers, 3.66% arterial leg ulcers, 14.66% ulcers of mixed venous and arterial origin and 13.5% vasculitic ulcers. In the Swedish population of Skaraborg, Nelzen found a venous origin in 54% of the ulcer patients. Each leg ulcer needs a clinical and anamnestic evaluation. Duplex ultrasound is the basic diagnostic tool to exclude vascular anomalies especially chronic venous and arterial occlusive disease. Skin biopsies help to find a correct diagnosis in unclear or non-healing cases. In conclusion, chronic venous disease is the most frequent cause of leg ulcerations. Because 25% of the population have varicose veins or other chronic venous disease the coincidence of pathological venous findings and ulceration is very frequent even in non-venous ulcerations. Leg ulcers without the symptoms of chronic venous disease should be considered as non-venous.

Differential diagnosis of leg ulcers

In Germany about 0.7% of the adult population have a chronic leg ulcer. Although chronic venous insufficiency accounts for at least 80% of all chronic leg ulcers, knowledge of the relevant differential diagnostic considerations is of crucial importance, in particular for patients who are refractory to therapy. In addition to vascular disease, other causes include neuropathic, metabolic, hematologic and exogenous factors as well as neoplasias, infections, drugs, genetic defects and some primary skin disorders. For the long-term successful treatment of patients with chronic leg ulcers, it is necessary to identify all relevant factors, in order to enable a pathogenesis-oriented, interdisciplinary therapeutic approach.

Ulcus cruris associated with prolidase deficiency

Prolidase deficiency is an autosomal recessive disorder that is associated with chronic cutaneous ulcers, mental retardation, unusual facial appearance, skeletal deformities, joint dislocations, hematological anomalies, splenomegaly, and chronic infections. The most typical finding is chronic, recurrent leg ulcers appearing in early childhood. Prolidase (peptidase-D) is necessary for collagen biosynthesis and its deficiency leads to impairment in connective tissue of the skin, capillaries, and lymphatic vessels. We report a 33-year-old woman who had a 15-year history of nonhealing ulcer on left pretibial region accompanied by splenomegaly, hypochromic microcytic anemia, and thrombocytopenia. Prolidase deficiency is a rare genodermatosis and must be considered in the differential diagnosis of leg ulcers that develop at an early age.

Leg ulcers due to hyperhomocysteinemia

Chronic leg ulcers are rare in young adults and generally indicate a vascular cause. We report a case of a 26-year-old man with leg ulcers of eight months duration. Doppler study indicated venous incompetence and a postphlebitic limb. However, as the distribution and number of ulcers was not consistent with stasis alone and no features of collagen vascular disease were noted, a hyperviscosity state was considered and confirmed with significantly elevated homocysteine level in the serum. Administration of vitamins B1, B2, B6 and B12, trimethyl-glycine, mecobalamine, folic acid and povidone iodine dressings with culture-directed antibiotic therapy led to a satisfactory healing of ulcers over a period of one month. Hyperhomocysteinemia must be considered in the differential diagnosis of leg ulcers in young individuals.

Differential diagnosis of leg ulcers.

Differential diagnosis of leg ulcers.

Differential diagnosis of leg ulcers

There are various types of leg ulcers. The lesions may result from interference with venous outflow or from marked impairment of cutaneous arterial blood flow, or they may be associated with metabolic, hematologie, neoplastic, drug-induced, or with a miscellaneous group of conditions. The initiating factor is frequently trauma, although some of the ulcers may occur spontaneously. In determining the cause of a given leg ulcer, a knowledge of the relative frequency of the different types of ulcers, careful consideration of certain salient features of the patient's history and clinical examination, and proper use of the laboratory are diagnostically important.

The Differential Diagnosis of Leg Ulcers

The Differential Diagnosis of Leg Ulcers