Malum perforans L98.4

Chronic, painless, areactive, ulcerations of varying depth (sometimes extending to underlying bone) in anesthetic skin areas with pressure or constant trauma and lack of healing tendency. Most commonly, such neuropathic ulcers occur in diabetes mellitus.

Occurrence has been described in various underlying diseases including

• Diabetic polyneuropathy
• Diabetes mellitus (see below diabetic foot syndrome)
• Syringomyelia
• spinalis anterior syndrome
• peripheral nerve lesions
• leprosy
• syphilis ( tabes dorsalis)
• Acropathia ulcero-mutilans familiaris
• Acropathia ulcero-mutilans non-familiaris

S.a.u. trophoneurotic nasal ulcer

Varies depending on the cause. In most cases between 60.and 80.- LJ.

• Phlegmons
• Osteomyelitis
• Diabetic-neuropathic osteoarthropathy (Charcot's foot): Deforming disease of the joints and bones

• The all-important therapy regime is not symptomatic wound therapy, but pressure relief (due to the painlessness of the ulcer, there is no involuntary pressure relief).
• Cleansing of the ulcer by removal of the necrotic surfaces with a sharp spoon or/and ointments containing enzymes (e.g. Iruxol N ointment) or intra-site gel, dressing with hydrocolloid film (e.g. Varihesive extra thin) up to 0.5 cm above the edge, change approx. every 2-3 days (at the latest when the film leaks), until epithelialization, see also wound treatment. Plastic covering is often not very successful. Often such ulcerations cannot be healed completely, sometimes amputation is unavoidable. If there are signs of inflammation, antibiotic treatment according to an antibiogram, although systemically administered drugs are usually not very successful.
• For a success the treatment of causal factors is important, i.e.:
  • Treatment of the underlying disease (e.g. diabetes mellitus, alcoholism).
  • Relief of pressure points by adequate footwear (orthopedic shoes), soft positioning (e.g. bed), careful non-traumatizing foot care.
  • Education of the patient; due to a lack of pain sensation, pressure points are not perceived.

1. Frykberg RG (2003) Diabetic foot ulcerations: management and adjunctive therapy. Clin Podiatry Med Surgery 20: 709-728
2. Joseph WS et al (2003) Infections in Diabetic Foot Ulcerations. Curr Infect Dis Rep 5: 391-397
3. Kalra M et al (2003) Surgical treatment of venous ulcers: role of subfascial endoscopic perforator vein ligation. Surg Clin North Am 83: 671-705
4. Seidel C et al (1994) Therapeutic superiority of regional retrograde venous antibiotic pressure perfusion versus systemic venous infusion in diabetics with infected neuropathic plantar ulcers. Dermatologist 45: 74-79