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arterial ulcer

Etiology: 1) arterial insufficiency 2) peripheral arterial disease Clinical manifestations: 1) atrophic skin bordering ulcer 2) pallor on elevation of extremity 3) diminished pulses, cool skin 4) relatively painful lesions - pain may worsen at night - pain may worsen with elevation of extremities - pain may lessen with hanging the foot over the edge of the bed [4] 5) punched-out necrotic ulcers with surrounding erythema [1] - dry pale pick, gray or yellow wound bed [1] - generally no bleeding 6) distribution a) may appear random, but generally distal arterial supply b) over pressure areas & over bony prominences c) on digits d) frequently on lateral aspect of ankle [2] 3) pretibial areas * images [5,6] Special laboratory: 1) diminished ankle/brachial index (< 0.5-0.6) Differential diagnosis: - cholesterol embolization is suggested by infarction of the toes in association with livedo reticularis - venous stasis ulcer (see [6] for comparison) - occur most commonly near the medial malleolus - associated with signs of chronic venous insufficiency - often weep serous fluid - neuropathic ulcer - secondary to repetitive trauma to the skin, typically in patients with diabetic peripheral neuropathy with reduced awareness of pressure or trauma to the skin - neuropathic ulcers in diabetics are painless, most common on the plantar surface of the feet, callus & foot deformity are common Management: 1) avoid friction & pressure 2) dressing a) foam dressing b) hydrogel c) alginate dressing d) absorptive wound filler e) collagen-based dressing f) gauze g) do NOT use hydrocolloid dressing h) do NOT moisten an arterial ulcer if no healing potential, leave dry 3) do NOT debride ischemic arterial ulcer [2] 4) risk factor management [1] 5) measures to increase blood supply - limited evidence of benefit for cilostazol [1] 6) referral to vascular surgeon [1] - revascularization may facilitate wound healing [1]

Related

neuropathic ulcer peripheral arterial disease; peripheral artery atherosclerosis (PAD) pressure ulcer (decubitus ulcer, bedsore) venous stasis ulcer

General

cutaneous ulcer

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018.
  2. UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
  3. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  4. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  5. Gabriel A, Molnar JA (image) Medscape: Vascular Ulcers http://emedicine.medscape.com/article/1298345-overview
  6. London Health Sciences Centre. (image) Venous Stasis & Arterial Ulcer Comparison. http://www.lhsc.on.ca/Health_Professionals/Wound_Care/venous.htm
  7. Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ. 2006 Feb 11;332(7537):347-50 PMID: 16470058
  8. Rothaus C Evaluation and Management of Lower-Extremity Ulcers. NEJM Resident 360. Oct 19, 2017 https://resident360.nejm.org/content_items/evaluation-and-management-of-lower-extremity-ulcers