ESSENTIALS OF DIAGNOSIS
History of varicosities, thrombophlebitis, or postphlebitic syndrome.
Irregular ulceration, often on the medial lower legs above the malleolus.
Edema of the legs, varicosities, hyperpigmentation, red and scaly areas (stasis dermatitis), and scars from old ulcers support the diagnosis.
Patients at risk may have a history of venous insufficiency, family history, varicosities, obesity, or genetic diseases that predispose to venous insufficiency (see Chronic Venous Insufficiency, Chapter 12). The left leg is usually more severely affected than the right.
Classically, chronic edema is followed by a dermatitis, which is often pruritic. These changes are followed by hyperpigmentation, skin breakdown, and eventually sclerosis of the skin of the lower leg (Figure 6–37). Red, pruritic patches of stasis dermatitis often precede ulceration (Figure 12–2). The ulcer base may be clean, but it often has a yellow fibrin eschar that may require surgical removal (Figure 6–38) (eFigure 6–108). Ulcers that appear on the feet, toes, or above the knees should be approached with other diagnoses in mind.
Venous stasis ulcer. (Used, with permission, from Lindy Fox, MD.)
Ulcer—venous stasis ulcer. (Used, with permission, from Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley HS. The Color Atlas and Synopsis of Family Medicine, 3rd ed. McGraw-Hill, 2019.)
Venous stasis ulcer located over the medial malleolus. (Used, with permission, from K Zipperstein, MD.)
Because venous insufficiency plays a role in 75–90% of lower leg ulcerations, testing of venous competence is a required part of a leg ulcer evaluation even when no changes of venous insufficiency are present (see Chapter 12). Doppler examination is usually sufficient (except in the diabetic patient) to evaluate venous competence. Arterial insufficiency may coexist with venous disease. An ankle/brachial index (ABI) less than 0.7 indicates the presence of significant arterial disease and requires vascular surgery consultation.
The differential includes vasculitis (eFigure 6–109)(eFigure 6–110), pyoderma gangrenosum, arterial ulcerations, infection, trauma, skin cancer, arachnid bites, and sickle cell anemia. When the diagnosis is in doubt, a punch biopsy from the border (not base) of the lesion may be helpful.
Leukocytoclastic vasculitis. (Used, with permission, from Lindy Fox, MD.)
Leukocytoclastic vasculitis. Note that the characteristic purple color of the purpuric component. (Used, with permission, from Lindy Fox, MD.)