Leg ulcer - Altmeyers Encyclopedia - Department Vascular medicine

Synonym(s)

leg ulcer; Leg Ulcer; Lower leg ulcer

Definition
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Polyetiological skin defect (symptom) on the lower leg, which extends into the dermis or subcutis. At least the collagenous network of the reticular dermis is affected, but usually also deeper layers of the skin and subcutis. In complicated ulcers, the defect can also reach muscles, fascia and bony areas.

Classification
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Classification of venous leg ulcer by etiology:

Vascular diseases:
- Venous (see also venous diseases):
- Arterial:
- Vasculitis (or chronic inflammatory vasculopathies):
- Lymphatic (lymphedema)
Neuropathic disorders (see also neuropathic ulcer):
- Polyneuropathy in diabetes mellitus
- Idiopathic polyneuropathy
- Neuropathy in chronic terminal renal failure
- Alcohol toxic polyneuropathy
- Tabes dorsalis
- Syringomyelia.
Metabolic disorders:
- Diabetes mellitus
- Gout
- Prolidase deficiency
- Gaucher's disease.
Hematologic disorders:
- Coagulopathies:
  - Phospholipid antibody syndrome
  - Hereditary thrombophilias (e.g. AT III deficiency, protein C deficiency, protein S deficiency, factor II mutation, lupus anticoagulant)
  - Immune thrombocytopenia (Werlhof disease)
  - Consumptive coagulopathy
  - Purpura fulminans.
- Erythrocyte disorders (e.g. sickle cell anemia, thalassemia, polycythemia vera)
- Leukocyte disorders ( leukemia)
- Dysproteinemias ( cryoglobulinemia, plasmocytoma).
Drug-induced:
- Hydroxyurea
- Anagrelide (imidazoquinazoline; for essential thrombocythemia).
- Marcumar
- Nifedipine.
Traumatic, caused, for example, by:
- Pressure, cold, heat, cauterization, radiatio.
- Pressure sores, artifacts.
Neoplasms:
Infections (ulcus cruris infectiosum):
- Bacterial: Boils, ecthyma, tuberculosis, syphilis, anthrax, diphtheria, tularemia, leprosy.
- Mycoses: Subcutaneous Trichophyton-rubrum abscesses.
- Protozoa: Leishmaniasis
- Others: Filariasis
Other causes
Granulomatoses.

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Localization
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Depending on the etiology, there are preferred ulcer localizations.

Diagnosis
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Medical history, clinic, ultrasound Doppler examination, duplex sonography, light reflection rheography, arterial Doppler, laboratory parameters (blood sugar, factor XIII, zinc level), histology, X-ray image, phlebography, lymphography, arteriography.

Complication(s)
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Type IV sensitization to local therapeutic agents (especially to wool wax alcohols), risk of osteomyelitis in case of deep-reaching defects.
Marjolin ulcer: If a chronic leg ulcer persists for years, a malignant transformation cannot be excluded (Marjolin ulcer). In this case, squamous cell carcinomas with a poor prognosis develop, more rarely basal cell carcinomas.

Therapy
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See the respective clinical picture listed under Etiology.

Tables
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Etiology	Diseases	Frequency in inpatients (%)*	Frequency in non-selected patients (%)
Exclusively venous genesis	e.g. with CVI	17	70-80
Exclusively arterial genesis	e.g. with pAVK	1	4
Mixed venous-arterial			9,5
Other causes			9,5

Polyätiological	2-fold or 3-fold combinations of different causes (in total)	> 80
	Venous and arterial genesis + vasculitis	17
	Venous and arterial genesis + polyneuropathy	8
	Other combination ulcers (bacterial infections, Pyoderma gangraenosum, artifacts, traumas of any kind)	> 50

Note(s)
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Remember: A leg ulcer is not a diagnosis but only a symptom!

Literature
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Combemale P et al (2007) Malignant transformation of leg ulcers: a retrospective study of 85 cases. JEADV 21: 935-941
King B (2004) Is this leg ulcer venous? Unusual aetiologies of lower leg ulcers. J Wound Care 13: 394-396
Moffatt CJ, Frank's PJ (2004) Implementation of a leg ulcer strategy. Br J Dermatol 151: 857-867
Mayer W, Jochmann W, Partsch H (1994) Varicose ulcer: healing in conservative therapy. A prospective study. Vienna Med Weekly 144: 250-252
Rappoport L et al (2008) Occurrence of ulcer crurum in connection with the intake of Anagrelid. Act Dermatol 34: 132-134
Stücker M et al. (2003) On the pathogenesis of therapy-resistant leg ulcers. Dermatologist 54: 750-755
Trummer M et al (2002) Clinical relevance of + patch test reactions to lanolin alcohol. Contact Dermatitis 46: 118