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
Dermatitis and Venous Leg Ulcers
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
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.
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.
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.)
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.
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.
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
Table 247-1 Differential
Diagnosis of Extremity Ulcers*