This chapter focuses on common disorders of the hands, feet, and extremities.
VENOUS STASIS DERMATITIS AND VENOUS LEG ULCERS
The vast majority of leg ulcers are venous stasis ulcers resulting from chronic venous insufficiency.1 Chronic venous insufficiency is usually caused by episodes of phlebitis or varicose veins, both of which damage venous valves. This 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 253-1). Pruritus is common. Cellulitis and lymphangitis may complicate stasis dermatitis. The presence of honey-colored crust and pustules suggests secondary bacterial infection.
Venous stasis. [Photo contributed by University of North Carolina Department of Dermatology.]
Stasis ulcers often begin within areas of stasis dermatitis. The bilateral malleoli and the medial aspect of the calf are the most common sites of involvement. Diagnosis is clinical, and secondary infection is common. Table 253-1 lists the differential diagnosis of leg ulcers. Certain disorders, such as arterial ulcerations, pyoderma gangrenosum, and polyarteritis nodosa, require immediate attention. If peripheral pulses are diminished or absent, obtain vascular blood flow studies 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, suspect pyoderma gangrenosum. If the diagnosis is in question, consult with a dermatologist.
TABLE 253-1Clinical Features and Treatment of Common Extremity Ulcers |Favorite Table|Download (.pdf) TABLE 253-1 Clinical Features and Treatment of Common Extremity Ulcers
|Condition ||Clinical Features ||Treatment ||Comments |
|Venous stasis ||Dependent erythema, edema and orange-brown hyperpigmentation || |
Low- to mid-potency topical steroid
|Medial distal leg and pretibial leg |
|Pyoderma gangrenosum ||Superficial pustule/nodule that grows into a large, painful ulcer on lower extremity; purulent base with irregular, gun metal gray borders || |
Treat underlying disease, if present
Immunosuppressive/cytotoxic agents for recalcitrant disease
|Often associated with systemic disease: inflammatory bowel disease, rheumatoid arthritis, and myeloproliferative disorders |
|Diabetic/neuropathic ulcers ||Asymptomatic ulcer often occurring with diabetic neuropathy; “punched out” appearing with a thick rim of peripheral callous || |
Redistribution of pressure off the wound
Creation of moist wound environment
Debridement of nonhealing tissue
PO antibiotics for simple soft tissue infection
IV antibiotics for cellulitis and/or osteomyelitis
|Plantar surface underlying first and fifth metatarsal heads, great toe, and heel; may complain of burning, numbness, pruritus or paresthesia from associated neuropathy |
|Buruli ulcers ||Erythematous nodule that progresses to a painless ulcer with deep white and yellow necrotic ...|