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Chapter 253: Skin Disorders: Extremities

Rachna A. Bhandari; Dean S. Morrell

INTRODUCTION

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.

ULCERS

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.

FIGURE 253-1.

Venous stasis. [Photo contributed by University of North Carolina Department of Dermatology.]

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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. With acute exacerbation, 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 253-1Differential Diagnosis of Extremity Ulcers
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TABLE 253-1 Differential Diagnosis of Extremity Ulcers

Trauma

Injuries, burns, injections, decubitus, chilblains (pernio), neuropathic ulcers

Infections

Viral: herpes simplex virus, cytomegalovirus

Bacterial: gangrene, ecthyma gangrenosum, ecthyma secondary to Staphylococcusaureus and/or group A Streptococcus; osteomyelitis, methicillin-resistant S. aureus

Mycobacterial: Buruli ulcer (West Africa, Mycobacterium ulcerans), Bairnsdale ulcer (Australia, M. ulcerans), tuberculosis, leprosy

Fungal: blastomycosis, coccidioidomycosis, paracoccidioidomycosis, chromomycosis, mucormycosis

Spirochetal: syphilis, yaws

Parasitic: leishmaniasis, amebiasis, schistosomiasis

Bites

Spiders, scorpions, snakes

Metabolic

Diabetes, gout, calciphylaxis (cutaneous necrosis from small- and medium-sized vessel calcification in diabetes, end-stage renal disease, or hyperparathyroidism)

Vascular

Venous: varicose veins, venous insufficiency

Arterial: hypertension, arterial insufficiency, thrombosis, embolism

Vasculitis

Polyarteritis nodosa, vasculitis, collagen vascular disease, Behçet's syndrome

Malignancy

Cutaneous: squamous cell carcinoma, basal cell carcinoma

Lymphoma: T-cell or B-cell lymphoma

Hematologic

Polycythemia, sickle cell anemia

Dermatologic

Bullous pemphigoid, necrobiosis lipoidica

Drugs

Hydroxyurea

Treatment of venous stasis dermatitis and ulcers begins with leg elevation and the use of support stockings. Weeping eruptions should be treated ...

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