stasis dermatitis & leg ulcers - ucsf school of · pdf filestasis dermatitis & leg...
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Stasis Dermatitis
& Leg Ulcers
UCSF Dermatology
Last updated 10.5.10
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Module Instructions
The following module contains a number of
green, underlined terms which are
hyperlinked to the dermatology glossary, an
illustrated interactive guide to clinical
dermatology and dermatopathology.
We encourage the learner to read all the
hyperlinked information.
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Goals and Objectives
The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with stasis dermatitis and leg ulcers.
After completing this module, the learner will be able to:• Recognize the clinical presentation of stasis dermatitis• List treatment options and preventative measures for stasis
dermatitis
• Distinguish stasis dermatitis from cellulitis
• List the most frequent causes of leg ulcers and describe their presentations
• Describe proper wound care and treatment for leg ulcers
• Discuss when to refer leg ulcers to a specialist
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Mrs. Lillian Paulsen
Case One
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Case One: History
HPI: Mrs. Paulsen is a 74 year-old woman who presents to the dermatology clinic with leg discoloration for the past three months. The “rash” does not hurt, but occasionally itches. She has not tried any treatment.
PMH: diabetes (last hemoglobin A1c was 6.7), hypertension, obesity. No history of atopic dermatitis.
Medications: ACE-inhibitor, thiazide diuretic, sulfonylurea Allergies: none Family history: noncontributory Social history: lives with her husband in a nearby town Health-related behaviors: no tobacco, drug use, or
alcohol ROS: as above, no leg pain when walking or at rest
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Case One: Exam
Erythematous brown
hyperpigmented plaque
with fine fissuring and
scale located above the
medial malleolus on the left
lower leg
Right leg with varicosities
Notice the asymmetry?
Palpation of the left leg
reveals firm skin
suggestive of fibrosis
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Case One, Question 1
What is the most likely diagnosis?
a. cellulitis
b. erysipelas
c. stasis dermatitis
d. tinea corporis
e. atopic dermatitis
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Case One, Question 1
Answer: c What is the most likely diagnosis?
a. cellulitis (cellulitis is more acute with more erythema, well-demarcated without pruritus or scale)
b. erysipelas (a form of cellulitis caused by acute beta-hemolytic group A streptococcal infection of the skin)
c. stasis dermatitis
d. tinea corporis (would expect a sharply marginated, erythematous annular lesion with central clearing)
e. atopic dermatitis (adults with AD have a history of childhood AD and a different distribution of skin involvement)
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Diagnosis: Stasis Dermatitis
Stasis dermatitis typically presents with erythema, scale, pruritus, erosions, exudate, and crust• Usually located on the lower third of
the legs, superior to the medial malleolus
• Can occur bilaterally or unilaterally (more common in the left leg)
• Lichenification may develop• Edema is often present, as well as
varicose veins and hemosiderin deposits (pinpoint yellow-brown macules)
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Venous Insufficiency
Stasis dermatitis is a cutaneous marker of venous insufficiency Normally, venous blood returns from the
superficial venous system via perforating veins into the deep venous system Venous stasis occurs when the valves in the
deep or perforating veins become incompetent, causing reflux into the superficial system (venous hypertension)
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Venous Insufficiency
Risk factors for venous insufficiency:
• heredity • age (older) • female sex
Chronic venous disease is extremely common and is associated with a reduced quality of life secondary to pain, decreased physical function, and mobility
• pregnancy • obesity
• prolonged standing• greater height
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Venous Insufficiency
Early signs of venous insufficiency: • Tenderness
• Edema
• Hyperpigmentation
Late signs: • Lipodermatosclerosis (subcutaneous fat is replaced
by fibrosis, eventually impedes venous and lymphatic flow leading to edema above the fibrosis)
• Venous ulcers
• Scars that appears porcelain white and atrophic
• Telangiectasias
• Varicose veins
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What happened here?
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Lipodermatosclerosis
Stasis dermatitis can lead to fat
necrosis with the end stage being
permanent sclerosis
(lipodermatosclerosis) with
“inverted champagne bottle” legs
as seen here
Patients with
lipodermatosclerosis may also
have acute inflammatory
episodes that present with pain
and erythema (these episodes
can be mistaken for cellulitis)
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What happened here?
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Elephantiasis Verrucosa Nostra
Inflammation of the draining lymphatics (as occurs with cellulitis) results in damage to those vessels resulting in lymphatic insufficiency The overlying skin becomes
pebbly, hyperkeratotic, and roughUlceration in this setting (with
lymphatic and venous insufficiency) is significantly harder to treat and heal
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Case One, Question 2
Which of the following are complications of venous insufficiency?
a. Recurrent ulceration
b. Cellulitis
c. Contact dermatitis
d. Venous thrombosis
e. All of the above
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Case One, Question 2
Answer: e Which of the following are complications of
venous insufficiency?a. Recurrent ulceration
b. Cellulitis
c. Contact dermatitis
d. Venous thrombosis
e. All of the above
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Complications of Venous Insufficiency
Recurrent ulcers Cellulitis (open wound
provides a portal of entry for bacteria)
Contact dermatitis (from topical agents applied to stasis dermatitis or ulceration)
Venous thrombosis
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Stasis Dermatitis: Treatment
Important to treat both the dermatitis and the underlying venous insufficiency
• Application of super-high and high potency steroids to area of dermatitis
• Elevation (to reduce edema)
• Compression therapy with leg wraps
• Change wraps weekly, or more often if the lesion is very weepy
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Compression Therapy Works
PRIOR TO TREATMENT FOLLOWING TREATMENT
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Case Two
Mr. Patrick Baily
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Case Two: History
HPI: Mr. Baily is a 50 year-old gentleman who presents to his primary
care provider with pain in his left leg. He developed a “weeping spot”
a few weeks ago, which he tried treating with an over the counter
antibiotic ointment.
PMH: history of a DVT 5 years ago after a transatlantic flight, no
longer on anticoagulation, hypertension, type 2 diabetes
Medications: thiazide diuretic, ACE-inhibitor, sulfonylurea (Glyburide),
biguanide (Metformin)
Allergies: none
Family history: father with type 2 diabetes and hypertension
Social history: lives with wife in an apartment, works in construction
Health-related behaviors: smokes 1 cigarette/day
ROS: as above
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Case Two, Question 1
How would you describe Mr. Baily’s skin exam?
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Case Two, Question 1
Irregularly shaped
ulcer located on the
medial aspect of the
left ankle,
erythematous border,
exudative
Without undermining
(unable to probe under
the edges)
Pedal pulses are
present, 1+
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Case Two, Question 2
Given the history and exam, what type of
ulcer is on Mr. Baily’s left leg?
a. Arterial
b. Venous
c. Diabetic
d. Pressure
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Case Two, Question 2
Answer: b
Given the history and exam, what type of
ulcer is on Mr. Baily’s left leg?
a. Arterial
b. Venous
c. Diabetic
d. Pressure
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Venous Insufficiency Ulcers
Active or healed venous leg ulcers occur in ~ 1% of
the general population
Typically tender, shallow, irregular ulcers with a
fibrinous base that are always located below the knee • Usually located on the medial ankle or along the line of the
long or short saphenous veins
• Accompanied with leg edema, hemosiderin pigmentation, +/-
dermatitis of the leg
Patients may experience symptoms of aching or pain.
Discomfort may be relieved by elevation.
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Leg Ulcers
Causes of chronic leg ulcers include:• Venous insufficiency 45-60%
• Arterial insufficiency 10-20%
• Combination of venous and arterial 10-15%
• Diabetic 15-25%
• Malignancy, vasculitis, collagen-vascular diseases, and dermal manifestations of systemic disease may present as ulcers on the lower extremity
Smoking and obesity increase the risk for ulcer development and persistence (independent of the underlying cause)
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Case Two, Question 3
Which of the following is the most appropriate next
step in evaluating Mr. Baily?
a. Measure the blood pressure in the left arm and
left ankle
b. Recommend he quit smoking
c. Obtain a skin biopsy
d. Treat the ulcer with topical antibiotics
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Case Two, Question 3
Answer: a
Which of the following is the most appropriate
next step in evaluating Mr. Baily?a. Measure the blood pressure in the left arm and left ankle
(Mr. Baily’s DP pulse was weak suggesting possible co-
existent peripheral arterial disease)
b. Recommend he quit smoking (smoking cessation has been
shown to help wound healing and should be encouraged)
c. Obtain a skin biopsy (not necessary unless the diagnosis is
unclear or the ulcer does not respond to treatment)
d. Treat the ulcer with topical antibiotics (no, in fact topical
antibiotic ointments may lead to a contact dermatitis)
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Evaluation: Ankle/Brachial Index
Measure the ankle/brachial index (ABI) to exclude arterial occlusive disease• Compression therapy (used to treat venous insufficiency)
is contraindicated in patients with significant arterial disease
The ABI is the ratio of systolic blood pressure in the ankle to the systolic blood pressure in the brachial artery • Normal: ≥ 0.8 • < 0.8 = indication of peripheral arterial disease
ABI is reliable except in diabetes (it may be falsely high) An ABI should be performed in all patients with weak
peripheral pulses, risk factors for arterial occlusive disease (i.e. smoking, diabetes, hyperlipidemia), and when ulcers are in locations not consistent with venous ulcers
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Venous Ulcers: Evaluation
In addition to assessment of the ulcer, the physical exam of patients with leg ulcers should include the evaluation of peripheral pulses, capillary refill time, peripheral neuropathy, and deep tendon reflexes.
Diagnosis of venous leg ulcers can be made clinically, however, non-invasive vascular studies such as venous duplex ultrasound and venous rheography can help document the presence and etiology of venous insufficiency• Findings may warrant surgical intervention with endoscopic
venous laser ablation, which may prevent further complication
• Surgical intervention tends to be more helpful when the venous disease is limited
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Venous Ulcers: Treatment
Address the underlying cause (venous
insufficiency) as well as local wound care:• Leg elevation
• Keep the wound moist with a primary dressing
• Compression therapy (except with an ABI < 0.8) • Apply external compression (applied over a primary dressing)
with a high compression system such as a multilayer bandage
or paste-containing bandage (e.g. Unna’s boot, Duke boot)
• Treat dermatitis with topical steroids
• Treat infection with debridement of necrotic or infected
tissues and use systemic antibiotics for infection
• Measure the ulcer at each visit to document improvement
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Wound Care: The Primary Dressing
Keep the wound moist. A moist wound
environment promotes healing compared to air
exposure
Choice of dressings is less important than the
program of ulcer treatment outlined on the
previous slide
Semipermeable dressings that allow oxygen and
moisture to pass through (but not water) have
made the treatment of leg ulcers easier and
more effective
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Venous Ulcers: Treatment
Patient education is crucial in successful treatment:• Topical antibiotics should rarely or never be applied to leg ulcers
due to the high risk of developing allergic contact dermatitis
• Only cleanse the wound with saline. Avoid products like betadine
and hydrogen peroxide.
• Frequent manipulation of leg ulcers impedes healing. Dressings
can be changed as infrequently as once weekly.
• Venous hypertension is a chronic condition. Once healed, patients
benefit from elastic stockings with 20-30mmHg compression.
Patients with venous ulcers that do not
demonstrate response to treatment (reduction in
size) after 6 weeks should be referred to
dermatology
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Case Three
Mr. Robert Lund
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Case Three: History
HPI: Mr. Lund is a 60 year-old gentleman who presents to his primary care provider with a painful “sore” on his right lateral leg. He reports a history of a “cramping pain” in his calves when walking, but this current pain is more localized to the skin.
PMH: hyperlipidemia, hypertension, angina
Medications: statin, thiazide diuretic, sublingual nitroglycerin when needed, aspirin
Allergies: NKDA
Family history: father with an MI at age 65, mother with diabetes
Social history: lives with his wife, works in sales, 2 grown children
Health-related behavior: smokes ½ pack of cigarettes/day, one glass of wine nightly, no drug use
ROS: no shortness of breath or recent chest pain
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Case Three, Question 1
How would you describe Mr. Lund’s skin exam?
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Case Three, Question 1
“Punched out”
appearing ulcer with
sharply demarcated
borders
Minimal exudation
and surrounding
erythema
Dorsalis pedis pulse
is absent
ABI is 0.6
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Arterial Ulcers
Arterial ulcers are secondary to peripheral arterial disease
Occur on the lower leg, usually over sites of pressure and trauma: pretibial, supramalleolar, and at distant points, such as toes and heels
Appear as “punched out,” with well-demarcated edges and a pale base
Exudation is minimal Associated findings of ischemia: loss of hair on feet
and lower legs, shiny atrophic skin
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Arterial Ulcers
Pulses (dorsalis pedis and posterior tibial) may be diminished or absent
Stasis pigmentation and lipodermatosclerosis are absent
Associated with intermittent claudication and pain• As disease progresses, pain and claudication
may occur at rest• Unlike venous ulcers, leg pain often does not
diminish when the leg is elevated
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Case Three, Question 2
Which of the following recommendations
should take priority?
a. Encourage him to stop smoking
b. Make sure his blood pressure and
hyperlipidemia are under good control
c. Encourage him to ambulate
d. Refer to a vascular surgeon
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Case Three, Question 2
Answer: d Which of the following recommendations
should take priority?a. Encourage him to stop smokingb. Make sure his blood pressure and
hyperlipidemia are under good controlc. Encourage him to ambulated. Refer to a vascular surgeon (although all the
answer choices are correct, the main goal of therapy is the re-establishment of adequate arterial supply)
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Arterial Ulcers: Treatment
Refer to a vascular surgeon for restoration of arterial blood flow with percutaneous or surgical arterial reconstruction
Patients should stop smoking, optimize control of diabetes, hypertension, and hyperlipidemia
Weight loss and exercise are also helpful All types of ulcers require proper wound
care as outlined above in venous ulcer treatment
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Case Four
Mr. Ryan Stricklin
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Case Four: History
HPI: Mr. Stricklin is a 46 year-old gentleman who presents to
his primary care provider with lesions of the bottom of his
foot. He noticed these lesions a few months ago when he
was changing his socks at the gym. He reports keeping them
clean with hydrogen peroxide.
PMH: diabetes type 1 x 25 years, hernia repair 20 years ago
Medications: insulin (glargine and regular)
Allergies: none
Family history: noncontributory
Social history: lives alone, works as a realtor
Health-related behaviors: no tobacco, alcohol, or dug use
ROS: no fevers, sweats or chills
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Case Four, Question 1
How would you describe Mr. Stricklin’s skin exam?
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Case Four, Question 1
Callus has been debrided,
revealing ulcers on the
plantar foot
Able to undermine the
ulcers with a metal probe,
unable to track the ulcer to
the bone
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Diabetic (Neuropathic) Foot Ulcers
Peripheral neuropathy, pressure, and trauma play prominent roles in the development of diabetic ulcers Usually located on the plantar surface under
the metatarsal heads or on the toes Repetitive mechanical forces lead to callus,
which is the most important preulcerativelesion in the neuropathic foot
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Diabetic (Neuropathic) Foot Ulcers
Lifetime risk of a person with diabetes developing a foot ulcer may be as high as 25%
Risk factors for foot ulcers include:
• Cigarette smoking
• Past foot ulcer history
• Peripheral vascular dz
• Previous amputation
• Poor glycemic control
• Peripheral neuropathy
• Diabetic nephropathy
• Visual impairment
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Evaluation and Treatment
Diabetic patients with foot ulcers are often best managed
in a multidisciplinary setting (podiatrists, endocrinologists,
dietician)
Remove the callous surrounding the ulcer (together with
slough and non-viable tissue)
Probe the ulcer to reveal sinus extending to bone or
undermining of the edges where the probe can be passed
from the ulcer underneath surrounding intact skin
• Order an imaging study if concerned about bone
involvement
• Patients with suspected osteomyelitis should be admitted
to the hospital for evaluation and treatment
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Evaluation and Treatment
Topical dressings to maintain a moist environment
Platelet-derived growth factor gel may be locally
applied, which has been shown to improve wound
healing in diabetic foot ulcers
Protect the ulcer from excessive pressure
• Redistribute plantar pressures with casting or special
shoes (a podiatrist with expertise in the management
of the diabetic foot is extremely helpful in these cases)
• Restrict weight bearing of the involved extremity
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Case Four, Question 1
Which of the following statements about Mr.
Stricklin is likely to be true?
a. He has diabetic neuropathy
b. He should continue to use hydrogen peroxide
to keep his lesions clean
c. He should wear open-toed shoes
d. None of the above
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Case Four, Question 1
Answer: a Which of the following statements about
Mr. Stricklin is likely to be true?a. He has diabetic neuropathy (diabetic neuropathy
can cause a loss of protective pain sensation as well as motor dysfunction)
b. He should continue to use hydrogen peroxide to keep his lesions clean (not true. Hydrogen peroxide interferes with wound healing)
c. He should wear open-toed shoes (diabetic patients should avoid open-toed and pointed shoes)
d. None of the above
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Diabetic Foot Ulcers: Prevention
Education about ulcer prevention should be provided for all diabetic patients• Optimizing glycemic control helps prevent the neuropathy
associated with foot ulceration• Foot examinations should be performed at least yearly in all
patients with diabetes. This includes monofilament testing for neuropathy and clinical assessment for peripheral vascular disease.
• Patients should examine their own feet on a regular basis• Encourage smoking cessation (risk factor for vascular
disease and neuropathy)• Optimize treatment of hypertension, hyperlipidemia, and
obesity• If present, treat tinea pedis (to prevent the associated skin
barrier disruption)
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Case Five
Mrs. Melinda Dellinger
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Case Five: History
HPI: Mrs. Dellinger is a 50 year-old woman who presents to her primary medical provider with a 4-day history of new, very painful lesions on her hand and thigh. She initially thought these lesions were bug bites, but they now appear to be expanding and look more like ulcers.
PMH: inflammatory bowel disease (well-controlled) Medications: sulfasalazine daily, multivitamin, fish oil Allergies: no known drug allergies Family history: brother with ulcerative colitis Social history: lives with husband and 20 year-old daughter,
works full-time as a high school teacher Health-related behaviors: reports no alcohol, tobacco, or
drug use ROS: no fevers, joint pains, abdominal pain or diarrhea
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Case Five, Question 1
How would you describe the following skin findings?
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Case Five, Question 1
Ulcer with
undermined
violaceous
border, exudative
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Case Five, Question 2
Given the history and exam findings, Mrs. Dellinger’s primary care provider is concerned about pyoderma gangrenosum (PG) and made an urgent referral to the dermatology clinic.
Which of the following is true about PG? a. PG is a slow processb. PG is painlessc. A biopsy of PG is diagnosticd. Debridement of the ulcer will help the healing
processe. PG is often mistaken as a spider bite
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Case Five, Question 2
Answer: e
Which of the following is true about PG? a. PG is a slow process (not true. PG rapidly progresses)
b. PG is painless (not true. PG is often very painful)
c. A biopsy of PG is diagnostic (not true. There are no specific
histological features on skin biopsy)
d. Debridement of the ulcer ill help the healing process (no! In
fact, PG is triggered and made worse by trauma – a process
called pathergy)
e. PG is often mistaken as a spider bite (true! In fact, we
recommend you consider PG or MRSA when the diagnosis
of a brown recluse spider bite is at the top of your differential)
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Diagnosis: Pyoderma Gangrenosum
PG is an inflammatory ulcerative process mediated by influx of neutrophils into the dermis
Begins as a small pustule which breaks down and rapidly expands forming an ulcer
Undermined violaceous border Satellite ulcerations may merge with the central
larger ulcer
Rapid progression (days to weeks)
Can occur anywhere on body (most frequently
occurs on the lower extremities)
Can be very painful
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Pyoderma Gangrenosum
Triggered by trauma (pathergy) (insect bites, surgical debridement, attempts to graft)• PG is often misdiagnosed as a brown recluse spider bite
The majority of patients do not have an underlying condition. However, in every patient with PG, an underlying condition should be sought because it may be asymptomatic.• Inflammatory bowel disease (1.5%-5% of patients get
PG); rheumatoid arthritis; hematologic dyscrasias, malignancy
1/3 of PG patients have arthritis: seronegative, asymmetric, monoarticular, large joint
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Another Example of PG
Note the undermined violaceous border
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PG: Evaluation and Treatment
PS should be considered a dermatologic emergency and an urgent referral to a dermatologist should be considered
The diagnosis of PG is one of exclusion; there are no specific histological or clinical features
Although non-diagnostic, a skin biopsy is often performed to exclude other conditions
Treatment of the underlying disease may not help PG (often doesn’t)
Topical therapy: Superpotent steroids, topical tacrolimus
Systemic therapy: Systemic steroids, cyclosporine, tacrolimus, cellcept, thalidomide, TNF-inhibitors
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Take Home Points Chart
Characteristic Arterial Ulcer Venous Ulcer Diabetic Ulcer
Location Ankle, toes, and heels Medial region of the lower
leg
On soles, over bony
prominences
Appearance Irregular margin,
punched out edges, little
exudate
Irregular margin, sloping
edges, pink base, usually
exudative
Overlying callus,
undermined, red, often
deep and infected
Skin temperature Cold and dry Warm Warm and dry
Pain Present, may be severe Mild-moderate, unless
infected or with significant
edema
May be absent
Arterial pulses Diminished or absent Present Present or absent
Sensation Variable Present Loss of sensation, reflexes,
and vibration sense
Skin changes Shiny and taut, edema
not common
Erythema, edema,
hyperpigmentation,
lipodermatosclerosis
Shiny, taut, or doughy
Treatment Refer to vascular
surgeon, wound care
Compression is mainstay,
wound care
Remove callus, off-load
pressure
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Take Home Points
Stasis dermatitis is a cutaneous marker for venous
insufficiency
The most common types of leg ulcers include venous,
arterial, combined (venous and arterial), and diabetic
Diagnosis of leg ulcers may be made clinically, but
evaluation with non-invasive vascular imaging and the
ABI will often guide treatment
Treatment of venous leg ulcers includes leg elevation,
compression, and wound care
Patients with arterial ulcers should be referred to a
vascular surgeon for restoration of arterial blood flow
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Take Home Points
A callus is the most important preulcerative lesion in
the diabetic foot
Osteomyelitis should be considered in patients
presenting with diabetic foot ulcers
Education about ulcer prevention should be
provided to all diabetic patients
The diagnosis of PG should be considered in the
rapidly expanding painful ulceration of the lower leg
PG is a dermatologic emergency and patients
should be referred to a dermatologist
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End of the Module
Bergan JJ, et al. Chronic Venous Disease. N Eng; J Med 2006;355:488-98.
Boulton AJM, et al. Comprehensive Foot Examination and Risk Assessment. A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008;31:1679-1685.
Burton Claude S, Burkhart Craig, Goldsmith Lowell A, "Chapter 175. Cutaneous Changes in Venous and Lymphatic Insufficiency" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e: http://www.accessmedicine.com/content.aspx?aID=2994438.
Emonds ME, Foster AVM. ABC of wound healing. Diabetic foot ulcers. BMJ. 2006;332:407-410.
Grey JE, Enoch S, Harding KG. ABC of wound healing. Venous and arterial leg ulcers. BMJ. 2006;332:347-350.
James WD, Berger TG, Elston DM, “Chapter 35. Cutaneous Vascular Diseases” (chapter). Andrews’ Diseases of the Skin Clinical Dermatology. 10th ed. Philadelphia, Pa: Saunders Elsevier; 2006: 845-851.
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End of the Module
Kalish J, Hamdan A. Management of diabetic foot problems. J Vasc Surg
2010;51:476-486.
Miller O. Fred. Leg Ulcer Treatment. Presentation at Geisinger Medical
Center.
Philips T. “Chapter 17. Ulcers” in Bolognia JL, Jorizzo JL, Rapini RP:
Dermatology. 2nd ed. Elsevier;2008: 261-276.
Powell Frank C, Hackett Bridget C, "Chapter 32. Pyoderma Gangrenosum"
(Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell DJ:
Fitzpatrick's Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=2952781.
Robson MC, et al. Guidelines for the treatment of venous ulcers. Wound
Rep Reg. 2006;14:649-662.
Wolff K, Johnson RA, "Section 16. Skin Signs of Vascular Insufficiency"
(Chapter). Wolff K, Johnson RA: Fitzpatrick's Color Atlas & Synopsis of
Clinical Dermatology, 6e:
http://www.accessmedicine.com/content.aspx?aID=5189520.