Ulcers are abnormal breaks in the skin/mucous membranes. They can be due to arterial insufficiency or due to venous insufficiency. Other causes may be diabetic neuropathy, or simply pressure ulcers due to excessive pressure over a bony prominence.
Pathophysiology
Arterial ulcers are found distally as small deep lesions with well-defined borders and a necrotic base.
You will find them mostly over bony prominences, especially on the toes and heel
They are coupled with other features of arterial insufficiency which means impaired wound healing.
😷 Presentation
- Concomitant claudication - pain when walking.
- Critical limb ischaemia - pain at night.
- The ulcer often takes a very long time to develop with little/no healing and thus no granulation tissue.
- There may be areas of gangrene.
- Pain may be worse when raising the leg and improved by lowering the leg.
They are deep, pale, well defined, often small.
⚠️ Risk factors
- ⭐️ Peripheral arterial disease
- Smoking
- Diabetes mellitus
- Hypertension
- Hyperlipidaemia
- Increasing age
- Obesity
- Inactivity
On examination:
- Cold limbs
- Poor/absent pulses - remember to push against bone to feel pulses adequately.
- Maintained sensation - unlike neuropathic ulcers
🔍 Investigations
- ABPI (Ankle Brachial Pressure Index)
- >0.9 is normal
- 0.9 - 0.8 is mild
- 0.8 - 0.5 is moderate
- <0.5 is severe
🧰 Management
Urgent vascular review will be needed, and their management may include 3 types of treatment:
- Conservative - lifestyle changes such as smoking cessation, weight loss, and exercise.
- Medical - statin therapy, antiplatelet therapy (either aspirin or clopidogrel).
- Surgical - angioplasty ± stenting or bypass grafting.
Same treatment as PAD. Debridement and compression is not to be used in arterial ulcers.