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Leg ulcers - sorting out the symptoms

GPs Dr Keith Hopcroft and Dr Vincent Forte continue their series on how to make sense of common presentations

GPs Dr Keith Hopcroft and Dr Vincent Forte continue their series on how to make sense of common presentations

The GP overview

Chronic leg ulcer is a major problem in the UK, costing the NHS up to £600m per annum. It is reckoned that nearly 1% of the population may be affected by leg ulceration at some time during their lives. Recurrence is common. The vast majority have a vascular underlying cause.

Differential diagnosis

Common

• venous disease: 70% to 80% of leg ulcers

• peripheral arterial disease: about 15% of leg ulcers

• associated with systemic disease – diabetes (5% of ulcer patients), rheumatoid arthritis (8%)

• vasculitis

• gross oedema due to systemic causes, for instance CCF, renal disease, osteoarthritis, severe obesity, prolonged immobility from any cause

• chronic infection for instance after trauma, insect bite

Occasional

• drug misuse

• after primary Herpes zoster

• primary malignancy – squamous cell carcinoma, melanoma, malignant change in an existing ulcer

• secondary malignancy – metastases

Rare

• tropical infections

• AIDS

• TB

• systemic drug reaction

• factitious – self-inflicted (Munchausen's, personality disorder)

Typical investigations

Likely FBC, ESR, TSH, LFTs, U&Es, fasting glucose and RA factor, ankle brachial pressure index (ABPI).

Possible Swabs for bacteriology, cardiovascular assessment if appropriate.

Small print Duplex ultrasound.

• FBC, ESR, CRP, TSH, LFTs, U&Es, fasting glucose and RA factor should be used as a basic screen for systemic causes and background disease.

• Swabs for bacteriology are only useful if there is clinical evidence of viable tissue infection, such as cellulitis.

• Full cardiovascular assessment should be made if there is any suspicion of arterial insufficiency.

• ABPI should be assessed in both legs by hand-held Doppler. The test has a sensitivity of up to 95%; if <0.8, assume arterial disease is present. ABPI is of limited usefulness in patients with microvascular disease, such as RA, diabetes mellitus, systemic vasculitis; these conditions may cause a spuriously high result.

• Duplex ultrasound is the investigation of choice to assess arterial and venous insufficiency.


41190263

Dr Keith Hopcroft is a GP in Basildon, Essex

Dr Vincent Forte is a GP in Gorleston, Norfolk

This is an extract from the third edition of Symptom Sorter – published by Radcliffe Publishing, costing £24.95, ISBN-10 1 84619 195 5

Red flags Red flags

Pain from an ulcer is most frequently associated with an arterial aetiology.
Refer for biopsy if the ulcer has an atypical appearance or distribution, or fails to heal within 12 weeks of treatment. Beware neoplastic change in an existing ulcer. This is rare, but not to be missed.
Compression bandaging is dangerous in diabetes and arterial insufficiency. Do not prescribe it until they are ruled out. If in doubt about ABPI, refer for a vascular opinion.

sorter top tips Carefully describe the lesion; morphology, size and so on Leg ulcer

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