Venous and Arterial and Pressure Ulcers

Related Subjects: | Vascular Surgery: Introduction | Acute Limb Ischaemia | Ankle-Brachial Pressure Index (ABPI) and Peripheral Vascular Disease | Peripheral Arterial Disease (PAD) | Waterlow Score

🦵 Leg Ulcers are chronic wounds of the lower limb caused by impaired blood supply, pressure, or systemic disease. They are important to recognise, as correct diagnosis guides treatment - compression can heal venous ulcers but is dangerous in severe arterial disease. 📚 In exams, you should always consider venous vs arterial vs neuropathic causes first, but remember rarer systemic and malignant ulcers.

🧬 Pathophysiology

• Venous ulcers: Venous hypertension from valve incompetence or DVT → capillary leak → oedema → tissue hypoxia → ulceration.
• Arterial ulcers: Atherosclerotic obstruction → ischaemia → tissue necrosis, especially at distal pressure points.
• Neuropathic ulcers: Loss of protective sensation (e.g., diabetes) → repeated trauma/pressure at plantar sites.
• Inflammatory/autoimmune ulcers: Vasculitis or neutrophilic dermatoses (e.g., pyoderma gangrenosum).
• Malignant ulcers: Neoplastic transformation of chronic wounds (e.g., Marjolin’s ulcer).

📝 History Taking

• ⏳ Duration, recurrence, progression of ulcer.
• ⚡ Pain: severe rest pain (arterial), minimal pain (venous), painless (neuropathic).
• 🧑‍⚕️ PMH: diabetes, PVD, DVT, varicose veins, autoimmune disease, IBD.
• 💊 Drugs: anticoagulants, steroids, immunosuppressants.
• 👣 Risk factors: smoking, immobility, trauma, footwear.

👀 Examination

• 📍 Site: medial malleolus (venous), toes/heel (arterial), plantar foot (neuropathic).
• 🔍 Appearance: shallow/granulating (venous), punched-out (arterial), undermined edge (pyoderma), rolled edge (malignant).
• 🩸 Circulation: palpate pulses, capillary refill, measure ABPI.
• 🦶 Neurology: sensation, vibration, proprioception (for neuropathy).
• 🌍 Surrounding skin: eczema, lipodermatosclerosis, atrophy blanche, cellulitis.

🔎 Investigations

• 🩺 ABPI (Ankle–Brachial Pressure Index): >0.8 safe for compression; <0.5 suggests severe arterial disease.
• 🧪 Bloods: FBC, glucose/HbA1c, ESR/CRP (vasculitis, infection).
• 🩸 Doppler ultrasound: venous reflux, arterial stenosis.
• 📷 Imaging: angiography or CTA/MRA if arterial disease suspected.
• 🧫 Biopsy: if non-healing, atypical, or suspected malignant ulcer.

🟢 Venous Ulcers

• Description: Above medial malleolus, may extend circumferentially, sometimes bilateral.
• Features: Granulating base, oedema, varicosities, haemosiderin pigmentation, lipodermatosclerosis.
• Treatment: Compression therapy if ABPI >0.8, elevation, dressings, emollients/steroids for eczema, optimise nutrition/mobility.

🔴 Arterial Ulcers

• Description: Toes, heel, lateral malleolus; “punched-out”, cold, very painful.
• Features: Low ABPI, absent pulses, shiny hairless skin.
• Treatment: Urgent vascular referral → angioplasty, bypass. Analgesia. Amputation if non-salvageable.

🦶 Neuropathic Ulcers

• Description: Plantar pressure sites (heel, metatarsal heads), painless.
• Features: Loss of sensation, common in diabetes, alcoholism.
• Treatment: Pressure offloading (orthotics), regular podiatry, debridement, optimise glycaemic control.

🟠 Vasculitis Ulcers

• Description: Over tibia, irregular, inflamed.
• Features: Associated systemic signs: rash, arthralgia, renal impairment.
• Treatment: Immunosuppression (steroids, azathioprine, biologics), specialist input.

🟣 Pyoderma Gangrenosum

• Description: Painful, violaceous undermined edge. Pathergy (worsens after trauma/debridement).
• Features: Linked to IBD, RA, haematological disease.
• Treatment: ❌ Avoid surgical debridement. Systemic steroids, ciclosporin, biologics. Specialist referral essential.

🧫 Malignant Ulcers

• Description: Non-healing ulcer, may arise from chronic venous ulcer (Marjolin’s).
• Features: Raised/rolled edge, contact bleeding, resistant to standard care.
• Treatment: Biopsy, wide local excision ± oncological therapy.

⚡ Traumatic Ulcers

• Description: From injury, esp. in diabetics or neuropathy.
• Features: At trauma/pressure sites.
• Treatment: Prevent recurrence, optimise footwear, wound care.

📊 Comparison Table: Venous vs Arterial vs Neuropathic Ulcers

Neuropathic Ulcer

📚 Summary & Exam Pearls

• 📍 Site + appearance often guides diagnosis.
• 🧮 Always measure ABPI before applying compression.
• 🩺 “Ulcer + varicose veins” → think venous. “Painful punched-out toe ulcer” → think arterial. “Painless plantar ulcer in diabetic” → think neuropathic.
• 🔬 Non-healing or atypical ulcers → always biopsy to rule out malignancy.