Leg skin ulcer with atypical features: vascular wound or advanced melanoma?

BACKGROUND: Leg ulcers have various etiologies, including malignancy, although vascular issues are the most frequent cause. Malignant wounds present diagnostic challenges, with a reported prevalence rate ranging from 0.4% to 23%. This significant variability in reported prevalence appears to be due to the different settings in which data are collected, which suggests potential influence by medical specialty. Consequently, the misdiagnosis of neoplastic ulcers (eg, ulcerated melanoma) as vascular wounds is relatively common, leading to delayed diagnosis, inadequate treatment, and a dramatic worsening of the patient's prognosis. Identifying malignancy in nonresponsive wounds involves recognizing signs such as hypertrophic granulation tissue, bleeding, unusual pigmentation, and raised edges. The appearance of the perilesional skin, together with dermoscopic observation, is also crucial to differentiation. Ultimately, a biopsy may provide valuable diagnostic clarification. CASE REPORT: A case is presented of lower limb melanoma that for years was misdiagnosed as a vascular wound by multiple specialists, with delayed referral to a dermatologist and resulting recognition and diagnosis, at which time nodular satellite metastases were found. Dermoscopy and biopsy confirmed the diagnosis. The disease was already advanced, with in-transit and distant site metastases, and the prognosis was regrettably poor. CONCLUSION: This case underscores the importance of early detection and accurate diagnosis of malignant wounds, emphasizing the need to refer patients with suspicious nonresponsive ulcers to a dermatologist.

[Chronic wounds of the lower limbs: a guide for non-specialists]. / Plaies chroniques des membres inférieurs : un guide pour le non-spécialiste.

Chronic lower-extremity ulcers are a growing public health problem, resulting in significant costs for society and patients, and having a significant impact on the quality of life of patients and informal caregivers. As general practitioners are often solicited early on, the acquisition of basic knowledge regarding wound care management is therefore essential to initiate local care, to make an early diagnosis and identify emergencies and patients that need a referral. The CASE and TIMERS frameworks enable a holistic assessment of the patient and the wound, to propose a treatment of the wound based on its etiology combined with appropriate local wound care. This framework allows also to identify atypical, severe, or recalcitrant wounds requiring specialized advice.

Les plaies chroniques des membres inférieurs sont un problème grandissant de santé publique, occasionnant des dépenses conséquentes et entraînant une répercussion non négligeable sur la qualité de vie des patients et de leurs proches aidants. Les médecins de premier recours étant le plus souvent les premiers intervenants, l'acquisition d'un socle commun de connaissances est donc essentielle pour la bonne prise en soin initiale des plaies chroniques, obtenir un diagnostic précoce et identifier les urgences et les patients à référer. L'approche selon les principes CASE et TIMERS permet une évaluation holistique du patient et de sa plaie, et de proposer un traitement étiologique associé à des soins locaux adaptés. Celle-ci permet également d'identifier les plaies atypiques, sévères ou récalcitrantes, nécessitant un avis spécialisé.

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.

A case of lower limb ulcer caused by hydroxyurea in treating primary thrombocytosis.

Hydroxyuria is a common medication for treating blood system diseases, but ulcers in the lower limbs caused by this medication are often rare and not often suspected. We reported an elderly patient with lower limb ulcers caused by hydroxyurea treatment for primary thrombocytosis. When hydroxide is used, close observation of skin lesions and prompt handling of any skin disruption should prevent ulcers.

32-year-old Traumatic Arteriovenous Fistula Presenting With Leg Ulcer and High-output Heart Failure.

Traumatic arteriovenous fistula (AVF) is not a common disorder, and dermatological signs and heart failure caused by AVF are rarely reported. We present the case of a 55-year-old woman who was referred for congestive heart failure symptoms. Echocardiography revealed preserved left ventricular ejection fraction. Due to edema of the right leg with a long-standing leg ulcer and palpable femoral thrill, duplex ultrasonography was performed. It showed an AVF between the right superficial femoral artery (SFA) and the right femoral vein (FV). The patient recalled a 32-year-old gunshot injury that was not medically treated. After the diagnosis of AVF she was referred to a surgeon for an AVF ligation, with subsequent resolution of her symptoms. The differential diagnosis of leg ulcer with leg edema should include the possibility of AVF as a cause.

Diagnosing and Managing Venous Stasis Disease and Leg Ulcers.

Venous insufficiency is a common medical condition that affects many individuals, especially those with advanced age. Chronic venous insufficiency can lead to secondary cutaneous changes that most commonly present as stasis dermatitis but can progress to more serious venous ulcers. Although venous ulcers are the most common cause of lower extremity ulcers, the differential diagnosis of leg ulcers is broad. This article will discuss clinical clues to help guide patient workup and will review basic clinical evaluation and management of common leg ulcers.

The evolution of leg ulcer guidelines and recommendations.

BACKGROUND: Clinical guidelines aim to consolidate and incorporate the latest evidence and opinion to improve patient outcomes and reduce variations in practice. AIMS AND METHODS: This article will examine the evolution of clinical guidelines and recommendations in leg ulcer assessment and management, from the seminal Royal College of Nursing clinical guideline (1998) to the current Leg Ulcer Recommendations from the National Wound Care Strategy Program (2023). The evolving definitions of leg ulcers will be discussed, as well as the multidisciplinary approach needed to manage the underlying aetiology of this condition. FINDINGS AND CONCLUSION: A national appetite for improving leg ulcer assessment and treatment, is being informed by clinical guidelines and recommendations. The cornerstones of assessment and management remain constant, although some fundamental elements around ankle brachial pressure index ranges, historically used to aid diagnosis of leg ulcer aetiology, have been omitted in the recent recommendations.

Development of a localization-based algorithm for the prediction of leg ulcer etiology.

BACKGROUND: Diagnostic work-up of leg ulcers is time- and cost-intensive. This study aimed at evaluating ulcer location as a diagnostic criterium and providing a diagnostic algorithm to facilitate differential diagnosis. PATIENTS AND METHODS: The study consisted of 277 patients with lower leg ulcers. The following five groups were defined: Venous leg ulcer, arterial ulcers, mixed ulcer, arteriolosclerosis, and vasculitis. Using computational surface rendering, predilection sites of different ulcer types were evaluated. The results were integrated in a multinomial logistic regression model to calculate the likelihood of a specific diagnosis depending on location, age, bilateral involvement, and ulcer count. Additionally, neural network image analysis was performed. RESULTS: The majority of venous ulcers extended to the medial malleolar region. Arterial ulcers were most frequently located on the dorsal aspect of the forefoot. Arteriolosclerotic ulcers were distinctly localized at the middle third of the lower leg. Vasculitic ulcers appeared to be randomly distributed and were markedly smaller, multilocular and bilateral. The multinomial logistic regression model showed an overall satisfactory performance with an estimated accuracy of 0.68 on unseen data. CONCLUSIONS: The presented algorithm based on ulcer location may serve as a basic tool to narrow down potential diagnoses and guide further diagnostic work-up.

Efficacy and safety of pentoxifylline for chronic venous leg ulcers: study protocol for a multicenter randomized controlled trial in China (ESPECT study).

BACKGROUND: Venous leg ulcers (VLUs) are the most severe manifestation of chronic venous disease, with long healing time and a high recurrence rate. It imposes a heavy burden on patients, their families, and the health care system. Chronic inflammation triggered by sustained venous hypertension is now recognized as the hallmark of chronic venous disease. The anti-inflammatory effect of pentoxifylline may offer a promising avenue to treat VLUs. However, current evidence of pentoxifylline for VLUs is relatively small and of low quality. The aim of this study is to evaluate the efficacy and safety of pentoxifylline for VLUs in the Chinese population. METHODS: This is a randomized, double-blinded, double-dummy, multi-center, placebo-controlled clinical trial. A total of 240 patients will be randomized to receive pentoxifylline (400 mg, twice daily) or placebo for 24 weeks. All participants will receive diosmin treatment and standard care of VLUs and other comorbidities. The primary outcome is the difference in the wound healing rate within 12 weeks between pentoxifylline and placebo. Secondary outcomes include (1) percent wound size changes at 12 weeks, (2) the levels of TNF-α and IL-6, (3) venous clinical severity score and chronic venous insufficiency quality of life score, and (4) ulcer recurrence within 24 weeks. DISCUSSION: This study would evaluate the efficacy and safety of pentoxifylline for VLUs in the Chinese population. If confirmed, it wound offer another effective and safe therapeutic option for treatment of VLUs. TRIAL REGISTRATION: The trial was registered at the Chinese Clinical Trial Registry (No. ChiCTR-2100053053). Registered on 10 November, 2021, https://www.chictr.org.cn/showproj.aspx?proj=137010.

The effectiveness of adalimumab as an add-on therapy in two cases with leg ulcers in Behçet's disease resistant to conventional immunosuppressive therapy alone and a review of the literature.

The current report presents two cases with leg ulcers related to Behçet's disease (BD) resistant to conventional immunosuppressive therapy (CIST) but successfully treated with adalimumab (ADA). BD, which can affect vessels of any size and type, is a systemic vasculitis. In the vascular system, veins are the most predominantly affected blood vessels, with deep vein thrombosis and recurrent superficial vein thrombophlebitis being the most common vascular signs of the disease in the lower extremities. Leg ulcers, commonly associated with vasculitis or deep vein thrombosis, are rare in patients with BD. Conventional immunosuppressive therapy is very critical to prevent relapses and diminish the risk of post-thrombotic syndrome. In patients with BD-associated venous thrombosis (deep vein thrombosis or superficial vein thrombophlebitis) resistant to these treatments, tumour necrosis factor-α inhibitors can be used alone or in combination with traditional disease-modifying antirheumatic drugs. In view of such information, add-on adalimumab treatment was considered appropriate for both patients. Response to this intervention was highly satisfying for the patients at the end of the 6-month treatment. Nonetheless, it warrants further studies directly evaluating the efficacy of tumour necrosis factor-α inhibitors alone in leg ulcers in BD.

What Is the Role of Allergic Contact Dermatitis in Patients with Lower Leg Ulcers?

GENERAL PURPOSE: To analyze the relationship between contact dermatitis and delayed wound healing, discuss the diagnosis and treatment of lower leg contact dermatitis, and provide an algorithm for the patient with a red leg and delayed wound healing. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Describe the nature of contact dermatitis.2. Distinguish between allergic and irritant contact dermatitis and the other major differential diagnoses of delayed wound healing in this clinical scenario.3. Outline the steps in the diagnosis of allergic contact dermatitis and irritant contact dermatitis and identify common haptens responsible for allergic contact dermatitis in patients with venous leg ulcers.4. Apply the algorithm for delayed wound healing on a background of lower leg dermatitis.

Lower leg ulcers are a common clinical presentation to wound care clinics. They are often associated with the presence of dermatitis on the periwound skin, which can be a factor in delayed wound healing. Correctly diagnosing the underlying etiology is critical to reversing the breakdown in the skin barrier function. The author discusses allergic contact dermatitis as an etiology and describes the most common allergens, fragrances, and preservatives identified from a limited literature review. Patch testing is the criterion standard for the diagnosis of allergic contact dermatitis and is the most appropriate means of identifying causative allergens. An algorithm for the identification and treatment of lower leg dermatitis is provided to simplify the process.

Ulcerated skin evaluation by electrical impedance measurements.

In the presented study, the transdermal results from the areas surrounding the ulcerated skin areas were compared with those obtained from healthy skin tissue. The analysis of electrical parameters, such as the slope of the Nyquist plot, min. IM, min. RE, min. f, Imagine part index, Phase index, Real part index, and Magnitude index were conducted. Electrical parameters have been measured in the group without lower leg ulceration and in the group with lower leg ulcers. On the basis of the statistical analysis, it was determined that these parameters may be effective in the evaluation of the skin. In fact, the skin surrounding the ulceration was characterised by different values of electrical parameters as compared with healthy skin tissue. A statistically significant difference was found in the electrical parameters obtained for the healthy leg skin and the skin surrounding the ulceration. This study was to investigate the applicability of electrical parameters in the evaluation of the skin in lower leg ulcers. The electrical parameters can be used as an effective tool in assessing the condition of the skin, both healthy and surrounding the ulcerations. The most useful parameters in assessing skin condition using electrical parameters include min. IM, min. RE, min. f, Imagine part index, Phase index, and Magnitude index.

Evaluation of the ankle brachial index and toe brachial index for peripheral arterial disease diagnosis in patients over 70 years with lower limb ulcers.

OBJECTIVE: The aim of our study was to evaluate the diagnostic performance of the ankle brachial index using pulsed Doppler, and the toe brachial index using laser Doppler, in comparison with the arterial Doppler ultrasound of the lower limbs as a reference test, in a population of non-diabetic subjects over 70 years old with lower limb ulcers and without chronic renal failure. METHODS: We included 50 patients, 100 lower limbs from the vascular medicine department of the Paris Saint-Joseph hospital from December 2019 to May 2021. RESULTS: We found a sensitivity of 54.5% for the ankle brachial index and a specificity of 67.6%. Regarding the toe brachial index, the sensitivity was 80.3% and the specificity 44.1%. We could explain the low sensitivity of the ankle brachial index in our population by the mediacalcosis of elderly subjects, avoidable with the measurement of the toe blood pressure index, which had a better sensitivity. CONCLUSION: In a population of subjects over 70 years of age with a lower limb ulcer, without diabetes and without chronic renal failure, it would seem judicious to use the ankle brachial index in association with the toe brachial index for the diagnosis of peripheral arterial disease, followed by an arterial Doppler ultrasound of the lower limbs in order to evaluate the lesion profile of patients with a result of less than 0.7 of toe brachial index.

Patient-centered Outcomes for Individuals with a Venous Leg Ulcer: A Scoping Review.

GENERAL PURPOSE: To summarize randomized clinical trials addressing patient-centered outcomes of individuals with a venous leg ulcer. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Summarize the results of the review of randomized controlled trials addressing patient-centered outcomes of individuals with a venous leg ulcer.2. Identify the limitations of the research analyzed for the review.

To summarize randomized clinical trials addressing patient-centered outcomes of individuals with a venous leg ulcer with a scoping review. Authors searched PubMed using MESH terms for "venous ulcer" AND "randomized" for randomized clinical trials published from January 2002 to October 2021 that explored content-validated patient-centered outcomes for individuals with a clinically diagnosed venous leg ulcer. Authors also searched Cochrane Reviews from inception to April 15, 2022 for additional references using the same MESH terms. Studies in any setting were included if primary or secondary outcomes were venous ulcer-related mobility, pain or analgesic use, healing, infection, quality of life (including odor, social isolation, depression), amputation, or patient-level costs of treatment. Preclinical or nonrandomized clinical studies or those without venous leg ulcers were excluded. Authors tabulated interventions studied, numbers of patients treated per group, risk of delayed ulcer healing, and statistical significance of comparisons of 485 qualifying articles in Google Sheets. Authors graphically represented and tabulated frequencies of studies addressing patient-centered outcomes of individuals with venous ulcers. Studies mainly reported effects of compression, dressings, topical antimicrobials, or systemic therapy on patient healing or pain outcomes. Related ischemia, ultrasonography, or risk factors for delayed healing were not consistently reported, inflating variability of outcomes and decreasing consistency of differences reported. Research is needed on the mobility, amputation risk, infection risk, quality of life, and healthcare costs of patients with venous ulcers. Promising interventions include grafts, exercise, analgesics, electrical modalities, negative pressure, or vascular interventions. Consistently reporting each patient's baseline ischemia and vascular condition would improve relevance.

Clinical Manifestation of Cutaneous Leishmaniasis Following a Mechanical Trauma.

Unusual skin ulcers frequently represent a diagnostic challenge. When the most common disease entities such as arterial, venous or diabetic ulcers have been excluded, the question of further differential diagnoses and procedures arises. Other possible causes include chronic inflammatory diseases, neoplasia, self-inflicted wounds, primary infectious diseases and physical/chemical damage to the skin. To narrow down the differential diagnoses, a detailed history of the patient is essential, which also needs to include events further back in time.

Multimodality Treatment for Nonhealing Wound With Osteomyelitis in Sickle Cell Disease.

We treated a 25-year-old male sickle cell disease (SCD) patient with a long-standing wound of the lower limb with radiologically confirmed osteomyelitis of the tibia, successfully managed by multimodality treatment. Culture of the wound after sequestrectomy revealed a Staphylococcus aureus infection, which was treated with appropriate antibiotics as per culture and sensitivity results. The patient had been under treatment for the same since 3 years in his home country with no improvement. He had a history of a leg ulcer due to injury and as is common in SCD patients, the ulcer led to bone infection. He had taken long courses of antibiotics and surgical drainage of pus, which are the usual treatment modalities used in such patients, with extended periods to healing and long durations of pain and tenderness. In this case systemic antibiotics were used only for 7 days. Low-molecular-weight heparin and dextran, negative pressure wound therapy coupled with nano silver dressings and hyperbaric oxygen treatment for 15 days led to the patient being pain free within 10 days of instituting treatment. The patient healed completely after 1 year and has been incident free since the past 10 years. In essence, this case has shown that multi-modality treatment may lead to faster wound closure and reduction in pain in SCD patients suffering from osteomyelitis.