Chapter 210. Ischemic Ulcer

A 58-year-old woman with uncontrolled type 2 diabetes, hypercholesterolemia, and tobacco use presented with a 2-month history of a nonhealing ulceration on her left foot (Figure 210-1). She believes this started after she stepped on a tack. She presented with the ulcer, loss of protective sensation, and a nonpalpable posterior tibial pulse. She began treatment in a wound care center. Arterial noninvasive studies showed severe vascular disease and she underwent revascularization. While in the hospital, she quit smoking and gained control of her diabetes. Her ulcer healed and she continues to take her diabetes medications and does not smoke.

Ulcerations occur from ongoing biomechanical forces or trauma and require normal blood flow to heal. Nonhealing ulcers are commonly a result of peripheral ischemia seen in patients with diabetes and other vascular diseases. Treatment includes local wound care and improvement or correction of underlying factors causing ischemia. Untreated ischemic ulcers become infected and may require amputation of the affected area.

Arterial ulcer.

Of patients with diabetes, 15% to 25% will develop an ulcer at an annual incidence of 1% to 4%.1

Microvascular dysfunction is an important component of the disease process that occurs in diabetic foot disease. The abnormalities observed in the endothelium in patients with diabetes are not well understood and evidence suggests that endothelial dysfunction could be involved in the pathogenesis of diabetic macroangiopathy and microangiopathy.2 Microangiopathy is a functional disease where neuropathy and autoregulation of capillaries lead to poor perfusion of the tissues, especially at the wound base.

• Diabetes for more than 10 years, especially with poor glycemic control and the presence of other macro- or microvascular complications.
• Peripheral vascular disease from any cause or other vascular risk factors, including dyslipidemia and tobacco use.
• Neuropathy caused by loss of protective sensation and as a sign of microvascular disease.
• History of a previous ischemic ulcer.

Clinical Features

• Pain.
• Gray/yellow fibrotic base (Figures 210-1 and 210-2).
• Undermined skin margins.
• Punched-out appearance.
• Nonpalpable pulses.
• Associated trophic skin changes (e.g., absent pedal hair and thin shiny skin).

Typical Distribution

• Distal aspect of the toes.

Imaging

• Noninvasive studies ...