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May 2007: Lower limb lesions

What is the place of laser therapy in lower limb problems?

How can maggots be used therapeutically?

How has the management of varicose veins changed?

What is the place of laser therapy in lower limb problems?

How can maggots be used therapeutically?

How has the management of varicose veins changed?

?It is estimated that around 580,000 people have leg ulcers requiring treatment at any one time, costing the NHS £300-600 million a year.1 Of these, around 75% are venous in origin, associated with venous stasis, and around 60% will recur at least once despite the best efforts of primary care teams to prevent this.2 In the area of lower limb venous disease, technology has improved the management considerably. Treatment of the underlying cause with procedures such as endovascular laser and radiofrequency ablation will often help in the long term.

At the other end of the spectrum are the less common conditions such as cutaneous larva migrans, jellyfish stings and nodular non-suppurative panniculitis. With regard to the first two conditions, once practitioners are aware of their distinctive appearance patients can be reassured or treated appropriately, reducing the need for referral to secondary care.

1 Burns

Burns such as this hot water scald occur every day throughout the world. The majority, like the one shown here, will be managed at home or in primary care. Unless the wound is a severe full-thickness burn, pain will occur and adequate analgesia should be provided. There is still debate as to whether intact blisters should be ruptured. If left, the fluid provides an ideal medium for microbial culture but the base cannot be accessed for treatment; however, the intact skin does provide a hermetic barrier. As with any other open wound, always remember to check the patient's tetanus status.

2 Contact dermatitis

Odd or unusual distributions of dermatitis should always raise the question: is this contact dermatitis?

In this case the area affected was localised to the ankles, with a typical eczematous appearance. The cause was exposure to cement inside boots; the cement had irritated the skin and caused the rash. The area was itchy and sore and closer inspection revealed evidence of excoriation. If inflammation and exudate are present, always consider infection and treat with oral or topical antibiotics. Otherwise, remove the irritant, apply liberal amounts of emollients regularly and topical steroids once or twice a day. Where the rash is recurrent and the diagnosis difficult, patch testing may be indicated.

3 Erythema ab igne

Chronic repeated exposure of skin to moderate heat can result in the appearance of erythema ab igne. The distinctive rash has a reticulate appearance with erythema and hyperpigmentation. It is persistent and corresponds to the area of exposure, which may not be obvious in some cases. Erythema ab igne associated with the use of a laptop computer resting on the patient's thighs has been reported.3 In the case shown here the elderly lady regularly sat very close to an electric fire in her lounge and the rash had been present for a number of years. If the diagnosis is not clear then a punch biopsy can be performed.

In mild cases, removal of the heat may result in a gradual resolution; if this is not effective then treatment can be undertaken using the Nd:YAG, ruby or alexandrite laser to try to improve the appearance of these lesions.

As with solar-induced skin changes, malignant transformation can occur.4

4 Granuloma Annulare

Although, as the name suggests, granuloma annulare usually occurs as an annular rash, this is not always the case. This patient presented with a flat uniform area of hyperpigmentation in a symmetrical distribution over both ankles. It did not itch and there was no past history of eczema or psoriasis. In many cases a biopsy is not required. However, in this case because a diagnosis had not been made a biopsy was performed, which revealed the correct diagnosis. As this was asymptomatic and the patient was not troubled by its appearance, no treatment was necessary. The condition may resolve spontaneously. Successful treatment with imiquimod and tacrolimus has been reported.5,6

5 Jellyfish sting

There are 10,000 types of different jellyfish throughout the seas of the world. As more than 100 of these are toxic to humans, the results of contact with them are often seen around the shores of the world. This contact occurred in Dorset after the patient paddled close to the beach. The result was this bizarre rash, which was initially very painful. In other cases respiratory and cardiac arrest can occur,7 leading to death.8 In this case the initial urticarial rash was followed by bruising and post-inflammatory hyperpigmentation, which lasted for a number of weeks.

6 Cutaneous larva migrans

Cutaneous larva migrans is the most commonly acquired tropical dermatosis worldwide, descriptions of which date back more than 100 years. It has a distinctive appearance as an erythematous serpiginous pruritic cutaneous eruption over areas that have been in contact with sand, such as the feet. It is caused by hookworms, such as the dog hookworm or Strongyloides papillosus, a parasite of sheep, goats, and cattle.

Diagnosis is usually made from the typical appearance and no further tests are necessary. It is usually self-limiting without treatment, but many patients request treatment once they are aware of the diagnosis. Oral or topical thiobendazole is the treatment of choice, but cryotherapy may be used. This needs to be applied 1cm from the visible distal end of the larval burrow.9

7 Maggot therapy

Although not for everyone, maggot therapy can be a very useful adjunct to conventional treatment for leg ulcers. In this case the patient arranged delivery of the maggots to the surgery by post from a supplier in Wales. Accompanying them were detailed instructions of how they should be applied to the ulcer and watered for two to three days. This was straightforward and three days later the maggots were removed, leaving a very clean and healthy wound which healed rapidly with little further treatment. The patient reported minimal pain but did notice irritation from the movement of the maggots over the skin.10

8 Nodular non-suppurative panniculitis

Also called Weber-Christian disease, this form of panniculitis is characterised by recurrent episodes of fever associated with the eruption of single or multiple subcutaneous nodules on the lower limbs. Once present they resolve over a few days, but commonly leave shallow depressions within the skin. The condition is more common in women. It may occur solely as a disease of the skin, but in more severe cases can also affect the lungs, heart, intestines, spleen, kidneys and adrenal glands and may result in significant morbidity and mortality.

Although there is no uniformly successful treatment for this condition, therapeutic responses have been reported with drugs such as azathioprine, thalidomide, cyclophosphamide and tetracylines.11

9 Arterial ulceration

Arterial ulcers are usually located more distally than venous ulcers, especially on the dorsum of the foot and toes. They usually have a more distinct appearance, with irregular edges and a base that is more likely to appear greyish and unhealthy. When cleaned and dressed they have less tendency to bleed than venous ulcers and are more likely to be associated with pain. Other clues to their aetiology include the presence of hairless pale skin and absent pulses. Management needs to address the underlying vascular insufficiency.

10 Venous ulceration

Unlike arterial ulcers, venous ulcers tend to affect the gaiter areas of the lower legs from the midcalf to the area level and just below the medial and lateral malleoli. They tend to be larger in area than arterial ulcers, but shallower with a moist granulating base. Whereas arterial ulcers tend not to bleed, venous ulcers will ooze venous blood when pressure is applied to their base. The rest of the leg will often be oedematous consistent with venous insufficiency, with mild pain that is relieved by elevation of the limb.

Unlike arterial ulceration where compression is contraindicated, triple-layer bandaging is the treatment of choice for venous ulceration.12 When the diagnosis is in doubt, a vascular referral may be required.

11 Varicose eczema

Often a precursor to venous ulceration, the presence of varicose eczema and lipodermatosclerosis may mean that a vascular referral is required. The skin looks red and dry, as in other forms of eczema, with a distribution over the lower limbs where the varicose veins are present. The cause of the varicose eczema is the increased pressure under the skin from venous insufficiency; this causes fibrin to be deposited around the vessels, preventing oxygen and other nutrients from reaching the tissue where it is required.

Although topical steroids and emollients can be of benefit, addressing the underlying venous deficiency may be required eventually.

12 Varicose veins

Treatments for varicose veins date back 2,000 years, but it is over the past ten years that real advances have been made. I recall as a student watching the tying and stripping of varicosities, only for them to recur.

Now the approach is much more scientific. Modern scanning methods such as duplex ultrasound and colour flow imaging allow accurate mapping of the venous pathways, after which specific vessels can be treated by modern methods such as endovascular laser and radiofrequency ablation.

Although these procedures rely on access to more expensive equipment, the approach is much less hit and miss. As this is a new procedure, long-term data do not yet exist. The main reported complications were tightness along the limb in 90%, bruising in 24% and phlebitis in 5%.13

For more information on this procedure, see the NICE guidance on the use of endovenous laser for the treatment of the long saphenous vein.13

Author

Dr Nigel Stollery
MB BS
GP, Kibworth, Leicestershire and clinical assistant in dermatology, Leicester Royal Infirmary

Hot water scald. Such burns are usually managed at home or in primary care Figure 1: Burns Contact dermatitis. Unusual distributions of dermatitis should raise the suspicion of contact dermatitis Figure 2: Contact dermatitis Erythema ab igne is caused by chronic repeated exposure of skin to moderate heat, in this case an electric fire Figure 3: Erythema ab igne Granuloma annulare. This usually occurs as an annular rash, but not always: this case presented as a flat hyperpigmented area symmetrically distributed over both ankles Figure 4: Granuloma annulare Jellyfish sting. This bizarre rash, initially very painful, arose from contact with a jellyfish in shallow water in Dorset Figure 5: Jellyfish sting Cutaneous larva migrans presents as a red serpiginous itchy track over areas that have been in contact with sand Figure 6: Cutaneous larva migrans Maggot therapy, can be a useful adjunct to conventional leg ulcer therapy Figure 7: Maggot therapy Nodular non-suppurative panniculitis, is characterised by recurrent fever associated with the eruption of single or multiple subcutaneous nodules on the lower limbs Figure 8: Nodular non-suppurative panniculitis Arterial ulcers usually occur more distally than venous ulcers, with irregular edges and a greyish, unhealthy looking base

Figure 9: Arterial ulceration Venous ulcers are generally larger than arterial ulcers, but shallower with a moist granulating base

Figure 10: Venous ulceration Varicose eczema presents as red dry skin over the lower legs where varicose veins are present Figure 11: Varicose eczema Varicose veins. Advances in technology have improved management Figure 12: Varicose veins

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