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This chapter focuses on common disorders of the hands, feet, and extremities and is organized into the following subgroups: ulcers, inflammatory conditions, cutaneous infections, and vascular cutaneous conditions.

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Venous Stasis Dermatitis and Venous Leg Ulcers

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The vast majority of leg ulcers are venous stasis ulcers resulting from chronic venous insufficiency. Risk factors for development of both venous stasis dermatitis and venous leg ulcers include heredity, older age, female sex, obesity, pregnancy, prolonged standing, and greater height.1

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Chronic venous insufficiency is usually caused by episodes of phlebitis or varicose veins, both of which damage venous valves. This situation results in poor venous return from the lower extremities, leading to increased hydrostatic pressure and lower extremity edema and stasis dermatitis.

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Clinical Features

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Dependent edema, erythema, and orange-brown hyperpigmentation characterize early stasis dermatitis. The medial distal legs and the pretibial leg are the areas most frequently affected. More chronic and severe cases may have bright weepy erythema and even ulceration (Figure 247-1). Pruritus is common. Bacterial infection may complicate stasis dermatitis. The presence of honey-colored crust and pustules suggest secondary bacterial infection. Cellulitis and lymphangitis may develop.

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Figure 247-1.
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Venous insufficiency. Pruritic stasis dermatitis with venous stasis ulcer. (Reproduced with permission from Wolff KL, Johnson R, Suurmond R: Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 5th ed. © 2005, McGraw-Hill, New York.)

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Stasis ulcers often begin within areas of stasis dermatitis. The medial and lateral malleolus and the medial aspect of the calf are the most common sites of involvement. The ulcer often has an aching quality with dependency. The ulcer has a punched out appearance with orange-brown hyperpigmentation at the borders and a moist pink base. Peripheral pulses are usually present.

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Diagnosis of stasis dermatitis and stasis ulcers is clinical. Usually, other signs of venous stasis are present (edema, hyperpigmentation, varicose veins, and scarring), making the diagnosis straightforward. With acute exacerbation, secondary infection is common. Coexistent allergic contact dermatitis should also be considered.

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If the ulcer does not have the clinical findings mentioned above, other diagnoses should be considered (Table 247-1). Certain disorders, such as arterial ulcerations, pyoderma gangrenosum, and polyarteritis nodosa require immediate attention. For instance, if peripheral pulses are absent and the patient has a history of claudication, vascular blood flow studies should be performed to exclude arterial ulcers. If the patient reports a rapidly developing ulcer that began as a pustule or erythematous nodule and has violaceous overhanging borders, pyoderma gangrenosum should be suspected. If the diagnosis is in question, consultation with a dermatologist is indicated.

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Table Graphic Jump Location
Table 247-1 Differential Diagnosis of Extremity Ulcers* 

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