4.3.3 Vascular Disease 4.3.3.1 Venous Ulcers Around 70% of leg ulcers are venous in origin [61–63] (Fig. 4.5). Older sources of data may present a higher percentage. However, in mod- ern medicine, the prevalence of venous ulcers is declining. This is attributed to the higher stan- dards of medical care currently practiced. The significance of compression therapy is well rec- ognized nowadays; the use of low-molecular- weight heparins prevents venous thromboem- bolism in high-risk situations. In addition, vein surgery has become minimally invasive.Venous insufficiency may coexist with peripheral arte- rial disease in 10–15% of patients with leg ulcers [63, 64]. In many cases, the direct trigger for ul- ceration is some external physical injury [1, 65]. Whereas in a healthy person mild injury does not cause significant damage, in patients with venous insufficiency the skin runs a much higher risk of developing ulceration. Histologically,microvessels in areas subjected to chronic venous hypertension become dilated and coiled; i.e., they have a glomerular appear- ance in intravital capillaroscopy.In the advanced disease, the number of functioning, perfused capillaries is markedly reduced [66–69]. The se- verity of cutaneous microangiopathy has been found to correlate closely to the development of clinical cutaneous trophic changes [66, 70]. Mechanisms of Formation. At present, the exact mechanism leading to the histologic pic- ture and tissue damage in venous insufficiency remains uncertain. Nevertheless, in recent years we have acquired an increased under- standing of certain physiological mechanisms involved in this process. In chronic venous insufficiency, the venous pressure (or venous hypertension) in the deep venous system may be transmitted to the superficial system. Partsch [71] suggested that venous insufficiency is characterized by peaks of pressure occurring with every muscle con- traction and transmitted to the capillary net- work. It is suggested that these pressure peaks have a progressive, gradual, destructive effect on the capillaries in the skin and subcutaneous tissues [72–74]. In addition, leakage of fluids from within the capillaries into the interstitium of the dermis and subcutaneous tissues results in edema. Whatever the mechanisms leading to edema, edema in itself has been shown to affect the quality of the skin. It induces sclerotic changes in subcutaneous tissue, with consequent interfer- ence of metabolic and gas exchange [75]. More- over, due to the presence of edema, lymphatic vessels and their valves are subjected to fibrotic changes, with a further reduction in normal lymphatic function and drainage of the tissues, which sets up a vicious cycle of edema [76, 77]. 4.3Mechanisms of Formation of Specific Types 41 Fig. 4.5a, b. Venous ulcers. a. Brown pigmentation of sta- sis dermatitis around the ulcer. b. Lipodermatosclerotic leg; varicosities are seen in the medial area of the foot 04_031_052 01.09.2004 13:55 Uhr Seite 41 Endothelial damage, therefore, is the result of edema with subsequent impaired oxygena- tion and interference of metabolic activity (and, perhaps, peaks of venous pressure). Inter- cellular adhesion molecules seem to play a sig- nificant role in the pathologic process, as re- flected by their expression on endothelial cells [78–81]. This process is followed by endothelial- leukocyte adhesion and the trapping of white cells within the capillaries. Loss of endothelial integrity, together with the increasing presence of white blood cells, may lead to the destruction of adjacent tissue, protracted inflammation, and fibrosis [82–86]. In addition to the above, numerous hypothe- ses have been put forward to explain the ex- act mechanism of skin damage and the de- velopment of ulceration in the presence of venous insufficiency. Two presented below are worth mentioning: 5 Pericapillary fibrin cuffs are a prom- inent histological feature of venous insufficiency. In 1982, Browse and Burnard [87, 88] suggested that ve- nous hypertension, transmitted to the capillary network, results in the distention of capillary walls and the widening of capillary pores. Subse- quently, fibrinogen molecules leak into the extracellular fluid, forming complexes of fibrin around the cap- illaries. The pericapillary fibrin layer is claimed to form a mechanical bar- rier, which prevents the transfer of oxygen and nutrients, leading to progressive damage to the skin and subcutaneous tissues. However, other researchers have in- dicated that the fibrin cuffs do not function as a barrier for oxygen transport [89]. If so, these cuffs only seem to reflect abnormal microcir- culation with transmural deposition of plasmatic macromolecules. 5 Falanga and Eaglstein [90] have suggested that growth factors may be trapped by certain macromole- cules leaking through the capillary pores into the dermis. Therefore, growth factors are unable to partici- pate and function in the processes of tissue repair. Location. The above discussion may help to explain the distribution of venous ulcers. Since venous pressure and the subsequent detrimen- tal effect on tissue is maximal distally, venous ulcers tend to occur in the lower calf. The me- dial malleolus is more commonly affected than the lateral. This finding is attributed to the anatomy of the venous system, in which a larg- er mass of venous vessels is located medially. Therefore, the medial aspects of the legs are subjected to higher venous pressures. Never- theless, not infrequently these ulcers may ap- pear above the lateral malleolus as well [91]. Lateral venous ulcers usually reflect the pres- ence of an incompetent lesser saphenous vein, with or without deep venous insufficiency.Oth- er characteristics of venous ulcers are detailed in Chap. 5. 4.3.3.2 Ulcers in Peripheral Arterial Disease Most patients with peripheral arterial disease are over the age of 70. In contrast to venous ul- cers, arterial ulcers are increasing in number. People live longer nowadays, and peripheral ar- terial disease is becoming more prevalent.Arte- rial ulcers are estimated to constitute about 10% of leg ulcers [64]. Mixed ulcers, of arterial and venous disease, are said to affect approxi- mately 10–15% of patients with leg ulcers [63, 64]. Mechanisms of Formation. In many cases, so-called ‘arterial’ ulcers develop following physical trauma [65]. The trauma may be mi- nor, but it affects vulnerable, poorly vascular- Chapter 4 Cutaneous Ulcer Formation 42 4 t t 04_031_052 01.09.2004 13:55 Uhr Seite 42 ized tissue, which is not able to heal as normal- ly vascularized healthy tissue does. Moreover, the trauma site may become the portal of entry for infectious agents, further aggravating ulcer- ation. In other cases, arterial ulcers may appear without trauma, when critical limb ischemia has developed. Beyond a certain degree of is- chemia, there is a complex chain of events that may end in necrosis. The definition of critical limb ischemia, according to the Trans-Atlantic Inter-Society Consensus Document on the Management of Peripheral Arterial Disease (The TASC Work- ing Group 2000), is based on a patient having chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial oc- clusive disease [92, 93]. The suggested inclusion criteria in TASC for critical leg ischemia were absolute ankle pressure below 50–70 mmHg or reduced toe pressure (<30–50 mmHg). Atherosclerosis of large arteries is the funda- mental process in the pathogenesis of chronic critical limb ischemia. It results in occlusion or severe narrowing of vessels, with subsequent reduction of blood flow and decreased perfu- sion to distal regions. Other parameters such as low blood pressure or the presence of anemia may influence the degree of ischemia, and hence the likelihood of progression to necrosis. Location. Since a high percentage of arterial ulcers are caused by trauma, arterial ulceration (above the threshold of critical limb ischemia) may develop anywhere on the lower calves. Ul- cers tend to appear in the lateral or pretibial ar- ea of the leg or on the dorsum of the foot (Fig. 4.6). Note that they may appear in the malleo- lar region as well. If critical limb ischemia has developed, it may be manifested by distal necrosis of the toes or forefoot (Fig. 4.7). This condition has a poor prognosis, and amputation may be required. The dorsum of the feet and heels may be affect- ed as well. Other characteristics of arterial ulcers are detailed in Chap. 5. 4.3.3.3 Peripheral Arterial Disease and Hypertensive Ulcers Hypertensive ulcers were described by Marto- rell in 1945 as ulcers located in the pretibial or lateral area of the leg. These ulcers were said to occur mainly in hypertensive women above the age of 60 [94]. Some suggest that the so-called Martorell’s ulcer represents a special variant of an arterial leg ulcer, which should not be re- garded as a separate entity. Others doubt the validity of this clinical term, based on nonspe- cific histologic features in leg ulcers clinically diagnosed as ‘Martorell’s ulcers’ [95, 96]. In any case, the elderly population is prone to develop- ing hypertension, as well as atherosclerotic changes within blood vessels. 4.3Mechanisms of Formation of Specific Types 43 Fig. 4.6. An ulcer in peripheral arterial disease Fig. 4.7. Arterial occlusion with significant ischemia, pending ulceration 04_031_052 01.09.2004 13:55 Uhr Seite 43 4.3.3.4 Embolus An acute, rapid development of limb ischemia is caused by emboli. An atheromatous plaque that becomes detached from a blood vessel wall is a relatively large embolus that occludes a large vessel and generally affects a specific ana- tomic region. Cholesterol emboli, on the other hand, are microemboli composed of cholesterol crystals, 100–200 µm, which may occlude many small arteries with the induction of multiple le- sions [97, 98]. 4.3.4 Leukocytoclastic Vasculitis Note that leukocytoclastic vasculitis may be in- duced by several types of infections, most com- monly Streptococcus group A, Mycobacterium leprae, and the hepatitis B and C virus [99]. Sometimes leukocytoclastic vasculitis may ap- pear following the use of certain drugs (see Chap. 16). 4.3.5 Connective Tissue and Multisystem Diseases Cutaneous ulcers appear in connective tissue diseases and multisystem diseases. A classical example is systemic lupus erythematosus (SLE), which may present in several forms. In most cases, ulcers in connective tissue diseases are attributed to vasculitis. For example, the in- cidence of cutaneous ulcers in idiopathic SLE patients is about 5%. The ulcers are usually lo- cated in malleolar or pretibial areas [100, 101] due to the vasculitic process. Vasculitis may al- so result in gangrene of the finger tips. Howev- er, SLE may also lead to a secondary form of anti-phospholipid syndrome with the subse- quent development of cutaneous ulcers. Simi- larly, the presence of cryoglobulins in SLE may lead to the formation of cutaneous ulcers locat- ed in the extremities. In rheumatoid arthritis, various forms of cu- taneous ulcers may be seen: leg ulcers or digital necrosis, due to the vasculitic process, similar to those of SLE; ulceration of subcutaneous nodules; and pyoderma gangrenosum, which may be found in rheumatoid arthritis. Pro- longed glucocorticoid therapy may be detri- mental to the quality of the skin in these cases, thus further hindering the repair of cutaneous ulcers. Vasculitic involvement may induce ulcera- tion in other connective tissue diseases, such as dermatomyositis, Sjögren’s syndrome, or scler- oderma. However, there may be other reasons for ulceration in connective tissue disease. For example, Raynaud’s phenomenon, which may be associated with connective tissue diseases, may result in digital ulceration. Similarly, the gradual damage to the quality of the skin in scleroderma predisposes to ulceration. 4.3.6 Hypercoagulable States Some of the ‘hypercoagulable’ conditions listed in Table 4.1, such as coumadin-induced necro- sis, heparin necrosis, or disseminated intravas- cular coagulation, are characterized by the de- velopment of micro-thrombi [102]. The histo- logic hallmark of these cases is the presence of fibrin thrombi (see Chap. 6). The occlusion of blood vessels by fibrin thrombi may manifest clinically as cutaneous ulceration. Other conditions listed in Table 4.1, i.e., pro- tein C deficiency,activated protein C resistance, protein S deficiency,and anti-thrombin III defi- ciency, classified under the heading ‘thrombo- philia’, may lead to vascular thrombosis. In many cases, the mechanism leading to ulcera- tion is not direct. Thrombophilia may result in deep vein thrombosis which, in itself, predis- poses to chronic venous ulceration [103, 104]. However,fibrin thrombi have been described in such cases as well [105]. Most of these cases have been associated with coumadin or hepar- in therapy. Conditions such as hyperhomocystinemia have been implicated in the formation of deep venous thrombosis with the subsequent devel- opment of venous ulcers [106]. To the best of our knowledge, it has never been described in the literature as having directly caused a cuta- neous ulcer through the formation of fibrin thrombi. Chapter 4 Cutaneous Ulcer Formation 44 4 04_031_052 01.09.2004 13:55 Uhr Seite 44 4.3.7 Metabolic Disorders: Diabetes Mellitus Diabetic ulcers are included in Table 4.1 under the term ‘metabolic ulcers’. The metabolic ab- normalities in diabetes may lead to the forma- tion of ulcers by several mechanisms, as de- tailed below. 4.3.7.1 Peripheral Arterial Disease and Atherosclerosis (Macroangiopathy) Peripheral vascular disease is more common in people with diabetes than in the rest of the pop- ulation. In the presence of additional risk fac- tors such as smoking, hyperlipidemia, or hy- pertension, the incidence is even higher. The prevalence of peripheral arterial disease in diabetic patients is between 20% and 40%, and it is regarded as a sign of premature aging of blood vessels [107–109]. A distinguishing feature of diabetes is that the ulcers tend to oc- cur more distally than they do in non-diabetic patients with peripheral arterial disease [110]. Diabetic ulcers due to peripheral arterial disease may therefore appear anywhere on the lower calves, usually on the lateral or pretibial aspect of the leg, dorsum of the foot, or malleo- lar region. As in peripheral arterial disease, ne- crosis of a distal toe or foot may develop if there is severe ischemia of a diabetic limb. In ad- vanced cases, widespread calcification may de- velop along the length of the media of the arte- rial wall. Hence, Doppler measurement of ankle blood pressure (and consequently ABI meas- urement) may indicate high pressures, which does not accurately reflect the true degree of is- chemia of the limb [110, 111]. 4.3.7.2 Neuropathy Neuropathy in diabetes affects sensory, motor, and autonomic fibers. It is estimated that al- most 30% of type-2 diabetic patients have neu- ropathy, while it affects 50% of patients over the age of 60 years [112]. Ulceration of the soles of diabetic patients is, in most cases, attributed to neuropathy [113, 114]. The detrimental effects of sensory, motor, and autonomic neuropathy are as follows: 5 Sensory neuropathy results in anes- thesia and loss of protective sensa- tion. 5 Motor neuropathy results in diffi- culty in activating certain muscle groups, resulting in inadequate dis- tribution of pressure on the sole while walking. Areas subjected to repetitive focal pressure may ulcer- ate or, alternatively, may develop a callus, which predisposes to ulcera- tion. The consequences of motor neuropathy are reflected in the pres- ence of typical foot deformities seen in diabetic neuropathy, such as pro- trusion of the metatarsal heads. Mal perforant is a common neuro- pathic ulcer of the sole, which ap- pears over the metatarsal heads [110]. 5 Autonomic neuropathy is associated with dry skin and further contrib- utes to fissuring and callus forma- tion. In addition, it leads to arteriov- enous shunting which, although ac- companied by increased blood flow, reduces nutritive cutaneous capil- lary flow [115, 116]. The above-mentioned processes may mis- lead the physician, due to the following phe- nomena: 5 Sensory neuropathy may conceal symptoms of intermittent claudica- tion and rest pain. 5 An ischemic foot may nevertheless be warm and pink on clinical exam- ination, due to autonomic neuropa- thy [115, 117, 118]. 4.3Mechanisms of Formation of Specific Types 45 t t 04_031_052 01.09.2004 13:55 Uhr Seite 45 The neuropathic process leads to the formation of ulcers on the sole or on the lateral and medi- al regions of the foot in diabetic patients (Fig. 4.8). Typically, a neuropathic ulcer of the sole is surrounded by circumscribed callus for- mation. Neuropathy and decreased sensation render the patient even more prone to trauma and subsequent ulceration, which may occur anywhere in the distal regions of the limbs. In some cases, the presence of neuropathy pre- vents early identification of an ulcer by the af- fected person, and appropriate intervention, therefore, is not carried out. 4.3.7.3 Microangiopathy in Diabetes Diabetic microangiopathy is characterized by the thickening of basal membranes and in- creased capillary permeability. In its advanced stages, it results in compromised gas exchange, a decrease in cutaneous pO 2 , and ischemia [110, 119]. The main clinical implications of microan- giopathy with respect to skin ulcers are as follows: 5 The ischemic changes described above (together with macroangio- pathy) cause additional damage to the skin, thereby increasing the probability of ulceration. The com- bination of macroangiopathy and microangiopathy seems to be the reason why diabetic ulcerations tend to be located more distally, compared with ulceration in non- diabetic peripheral arterial disease. 5 Microangiopathic involvement of the vasa nervosum results in diabet- ic neuropathy. Note: The effect of microangiopathy is most ob- vious in the kidneys and the retina. The possible influence of these vascular changes on ulcer for- mation in the diabetic leg is questionable and has not yet been fully evaluated. It is reasonable to assume that they affect capillary function [111, 120]. 4.3.7.4 Other Factors: Osteoarthropathy, Cheiroarthropathy Charcot’s osteoarthropathy describes a de- structive process of the joints, occurring in dia- betic neuropathy. It creates excessive focal pres- sure on the sole of the foot, predisposing it to ulcer formation. Another process is known as cheiroarthropathy, in which there is a thicken- ing of the skin with limitation of joint mobility and an abnormal gait, with subsequent inap- propriate weight distribution on the sole of the foot [121, 122]. 4.3.7.5 Reduced Resistance to Infections Infection is a frequent complication of dia- betes, which aggravates tissue damage. Dia- betes is associated with decreased phagocytic activity and decreased function of leukocytes Chapter 4 Cutaneous Ulcer Formation 46 4 Fig. 4.8. A neuropathic ulcer in diabetes t 04_031_052 01.09.2004 13:55 Uhr Seite 46 [123]. Chemotaxis of leukocytes and phagocy- tosis are impaired in poorly controlled diabetes [110]. Hyperglycemia has been found to inhibit the cellular transport of vitamin C into fibro- blasts and leukocytes, with reduced chemotaxis of leukocytes [124]. 4.3.7.6 Location of Ulcers in Diabetes In view of the above-mentioned pathologic characteristics of diabetes, even minor trauma or otherwise negligible superficial infection may be sufficient to induce ulceration. In a diabetic patient, ulcers may be located as follows: 5 Lateral or pretibial regions of the leg, dorsum of the foot, or malleolar regions, due to peripheral arterial disease and subsequent damage to the skin and subcutaneous tissue 5 Distal toes (Fig. 4.9) or distal forefoot, due to the severe ischemia of periph- eral arterial disease 5 Neuropathy predisposes to ulcera- tion mainly on the sole. Neverthe- less, the decreased sensation com- bined with increased susceptibility to trauma may occur anywhere on the distal limb. Osteoarthropathy further contributes to the formation of plantar ulcers. In summary, the classical diabetic ulcer appears on the sole. However, in view of the combination of several detrimental factors including macro- angiopathy, microangiopathy, neuropathy, and reduced resistance to infections, ulcers in dia- betes can, in fact, occur anywhere on the lower leg. 4.3.8 Hematologic Abnormalities 4.3.8.1 Hemolytic Anemia and Cutaneous Ulcers Most of the literature in the field of hemolytic anemia and cutaneous ulcers relates to sickle cell disease. Blood vessels occluded by the sludging of sickled erythrocytes are the histo- logic hallmark of an ulcer in sickle cell anemia. Sickle cells are relatively rigid, with a re- duced ability to alter their shape. It seems that the reduced deformability of sickled erythrocy- tes is a major factor leading to vascular occlu- sion and ulceration [125]. These features of sickled erythrocytes may significantly decrease blood flow, especially in capillary beds subject- ed to venous stasis [126]. Below a certain level of blood flow, there is a clumping of sickled erythrocytes with subsequent obstruction of blood vessels [125, 127]. The vascular occlusion leads to ulceration. When the level of oxygen is reduced, these processes are more pronounced. The causes of ulceration in other types of anemia such as thalassemia, hereditary sphero- cytosis, or pyruvate kinase deficiency are not fully understood. For example, leg ulcers are rare in α-thalassemia, but relatively common in severe β-thalassemia [128]. It is reasonable to assume that, in these cases, there is also a di- minished deformability of abnormal erythroc- ytes. The tendency for ulcers to appear in the gaiter area of the lower limbs suggests that there is an element of venous stasis that con- tributes to a reduction in blood flow. In certain types of hemolytic anemia such as hereditary spherocytosis, cutaneous ulcers have been reported to improve and heal follow- ing a splenectomy [129, 130]. In other cases of anemia, such as in β-thalassemia, no beneficial 4.3Mechanisms of Formation of Specific Types 47 Fig. 4.9. An ulcer on the toe of a diabetic patient t 04_031_052 01.09.2004 13:55 Uhr Seite 47 effect of a splenectomy has been observed [131]. A possible explanation for the above observation regarding hereditary spherocytosis has been suggested: During their passage through the spleen, red blood cells may lose a membrane lip- id. This change may lead to the entrapment of cells in the microvasculature, resulting in stasis with impaired oxygenation and the formation of cutaneous ulcers. A splenectomy prevents this sort of damage to red blood cells; their improved function and increased capacity of deformabil- ity leads to healing of the ulcers [125, 132]. 4.3.9 Nutritional Disorders In most cases, malnutrition is not a direct cause of ulceration. However, malnutrition does interfere with wound healing and has a detri- mental effect on the general condition of the patient. This issue is discussed in detail in Chap. 18. Conditions in which malnutrition may in- duce ulceration directly are: 5 Vitamin C deficiency 5 Noma (cancrum oris, necrotizing ulcerative gingivitis) 5 Tropical ulcer (tropical sloughing phagedena) Vitamin C deficiency results in impaired colla- gen synthesis with subsequent poor wound healing. The classical clinical descriptions of scurvy by Lind [133] documented the appear- ance of ulcers on affected skin, induced mostly by minor trauma. Boulinguez et al. [134] docu- mented three patients with scurvy presenting with ecchymotic purpura and hemorrhagic ul- cers of the lower limbs. However, vitamin C is an important factor not only in those relatively rare patients whose ulcers are caused directly by vitamin C defi- ciency. It is also very important to identify pa- tients with cutaneous ulcers (caused by other etiologies) who happen to be deficient in vita- min C. In these cases, vitamin C supplementa- tion may improve wound healing. In the latter two conditions, i.e., noma and tropical ulcer, the specific mechanisms leading to ulceration have not yet been identified, but it appears that opportunistic infection, related to the state of malnutrition, plays a significant role in their pathogenesis. 4.3.10 Other Causes Epithelial tumors and leg ulcers are discussed in Chap. 6, and a detailed review of drugs and cutaneous ulcers is presented in Chap. 16. References 1. Shai A, Halevy S: Direct triggers for ulceration in patients with venous insufficiency. Int J Dermatol (in press) 2. Reed BR, Clark RAF: Cutaneous tissue repair. Prac- tical implications of current knowledge. II. J Am Acad Dermatol 1985; 13:919–941 3. Robson MC, Stenberg BD, Heggers JP: Wound heal- ing alterations caused by infection. Clin Plast Surg 1990; 17: 485–492 4. Rietchel RL, Fowler JF: The role of age, sex and col- or of skin in contact dermatitis. In: Rietchel RL, Fowler JF (eds) In: Fisher’s Contact Dermatitis, 4th edn. 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Br J Surg 1991; 78: 210–211 Chapter 4 Cutaneous Ulcer Formation 50 4 04_031_052 01.09.2004 13:55 Uhr Seite 50 [...]... 5 .3. 2 5 .3. 3 5 .3. 4 5 .3. 5 5.4 5.4.1 5.4.2 5.5 5.5.1 Typical Location of Various Cutaneous Ulcers 56 Lower Legs 56 Fingers and Toes 59 Soles 59 Facial Ulcers 59 Genital Ulcers 60 The Ulcer’s Appearance and Its Surroundings 61 The Ulcer’s Margin 61 The Skin that Surrounds the Ulcer 62 The Primary Lesion from Which the Ulcer Originates 63 Ulcers Originating from a Plaque or a Nodule 63 5.5.2 5.5 .3 5.6 Ulcers. ..04_ 031 _052 01.09.2004 13: 55 Uhr Seite 51 51 References 86 Bradbury AW, Murie JA, Ruckley CV: Role of the leukocyte in the pathogenesis of vascular disease Br J Surg 19 93; 80: 15 03 1512 87 Browse NL, Burnand KG: The cause of venous ulceration Lancet 1982; 2 : 2 43 245 88 Burnand KG,Whimster I, Naidoo A, et al: Pericapillary fibrin in the ulcer-bearing skin of the leg: the cause of lipodermatosclerosis and. .. mobility in the diabetic foot Relationship to neuropathic ulceration Diabet Med 1988; 5 : 33 3 33 7 1 23 Ehrlichman RJ, Seckel BR, Bryan DJ, et al: Common complications of wound healing: prevention and management Surg Clin North Am 1991; 71 : 132 3– 135 1 124 Barbul A, Purtill W: Nutrition in wound healing Clin Dermatol 1994; 12 : 133 –140 125 Peachey RD: Leg ulceration and haemolytic anaemia: an hypotheses Br... characteristics that may direct the physician to the underlying cause are (a) the appearance of the ulcer’s margin and (b) the appearance of the skin around the ulcer Fig 5 .3 Bluish discoloration around an ulcer caused by peripheral arterial disease 05_0 53_ 070 01.09.2004 13: 56 Uhr Seite 62 62 Undermining Undermining is defined as the spread of the ulceration with involvement and destruction of tissue, located deep... regarding the history and physical examination of these ulcers 5.8.1 Venous Ulcers Fig 5.10 Ulcers of leishmaniasis in linear distribution Patients with venous insufficiency frequently complain of dull pain and heaviness associated 05_0 53_ 070 01.09.2004 13: 56 Uhr Seite 67 67 References with standing, usually accompanied by swelling of the legs These symptoms are relieved by walking and by elevating the legs;... loss It may be atrophic The nails appear brittle, distorted, and thickened Location of Arterial Ulcers In view of the fact that a high percentage of arterial ulcers are caused by trauma, arterial ulceration may develop anywhere on the lower calves Ulcers tend to appear on the lateral or pretibial aspects of the leg, or on the dorsum of the foot Note that they may appear in the malleolar region as well... longstanding disease, manifested by highly indurated skin on the lower third of the leg, which looks relatively thin compared with the edematous upper part Location of Venous Ulcers The discussion on mechanisms of venous ulcer formation in Chap 4 may help to explain the distribution of venous ulcers Since venous pressure and its detrimental effect on tissues is maximal distally, venous ulcers occur on the. .. inflammatory erythematous area, one should determine which component developed first: If the redness appeared following the development of the ulcer, it suggests that the ulcer area underwent secondary infection On the other hand, ulcers may develop in the course of cellulitis, when the infectious process itself results in ulceration of the skin 5 Ivory plaque: In atrophie blanche, the ulcer is located... syphilis and tuberculosis [87] and in three patients with multiple cholesterol emboli [88] 5 Dermatitis and excoriations: Dermatitis and excoriations around an ulcer may suggest the possibility that the ulcer developed because of a bacterial infection, following repeated scratching of the skin 01.09.2004 13: 56 Uhr Seite 63 Primary Lesion from Which the Ulcer Originated t 5 Erythema: In the case of an... Common Causes of Ulcers in Adults and Children 5.2.1 Adults There are certain diseases (see below) that cause more than 95% of cutaneous ulcers in the general adult population Determining Etiology t 05_0 53_ 070 It is therefore reasonable, as a first step, to check whether the ulcer belongs to one of the following diagnoses: 5 Venous ulcers 5 Ulcers due to peripheral arterial disease 5 Diabetic ulcers 5 Livedoid . to the presence of cryo- globulins [52]. Digital ulceration may also oc- cur in thrombocythemia and polycythemia ve- ra due to stasis of the blood and secondary thrombosis. 5 .3. 3 Soles When ulcers. Burnand KG: The cause of venous ul- ceration. Lancet 1982; 2 : 2 43 245 88. Burnand KG,Whimster I, Naidoo A, et al: Pericapil- lary fibrin in the ulcer-bearing skin of the leg: the cause of lipodermatosclerosis. in the diabetic foot. Relationship to neu- ropathic ulceration. Diabet Med 1988; 5 :33 3 33 7 1 23. Ehrlichman RJ, Seckel BR, Bryan DJ, et al: Com- mon complications of wound healing: prevention and