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This chapter focuses on common disorders of the hands, feet, and extremities.
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VENOUS STASIS DERMATITIS AND VENOUS LEG ULCERS
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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.
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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.
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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, 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.
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