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5 Interesting Facts of Arterial Ulcer (Ischemic Ulcer)
- The clinical presentation of an ulcer in an older patient with known atherosclerotic disease and/or diabetes mellitus should trigger consideration of an arterial ulcer. This concern is augmented when the ulcer appears punched out, when it lies on the lateral leg, or if there are other findings of peripheral artery disease (e.g., loss of hair, shiny skin appearance, purple-red toes).
- Weak or absent distal pulses is a supportive clinical finding.
- The most important immediate treatment is referral to a vascular surgeon for consideration of bypass grafting, angioplasty (with or without stent placement), and atherectomy.
- Treatment of predisposing factors, such as optimizing diabetes management, smoking cessation, and hypertension treatment and/or hyperlipidemia therapy, may slow progression of the disease.
- Arterial ulcers heal poorly unless blood flow is restored. Some patients may lose part(s) of one or more extremities.
Basic Information
Etiology and Risk Factors
- Arterial ulcers, also known as ischemic ulcers, are caused by insufficient delivery of blood by peripheral arteries. Most often this is due to atherosclerosis, which, in turn, causes partial or complete occlusion of one or more peripheral arteries. Although most cases are due to gradual occlusion of the arteries, in some cases the ulcers are caused by cholesterol emboli. These consist of an atheromatous plaque detached from a proximal source, which occludes a distal vessel.
- Arterial ulcers are more common in patients with diabetes mellitus, in cigarette smokers, and in the elderly.
Workup
Physical Examination
- Figure 1. Arterial ulcer of the shin associated with thin, shiny, hairless skin and reddish-purple toes in a patient with diabetes mellitus.From Chapter 14: necrotic and ulcerative skin disorders. In: Fitzpatrick JE, High WA, Kyle WL. Urgent Care Dermatology: Symptom-Based Diagnosis. Philadelphia, PA: Elsevier; 2017:231-252.
- Figure 2. Large, deep, punched-out ulcer in a patient with peripheral artery disease and cholesterol emboli.From the Fitzsimons Army Medical Center Collection, Aurora, CO.
- Figure 3. Patient with large, deep, sharply defined ulcer on the heel due to peripheral atherosclerotic disease.From the Fitzsimons Army Medical Center Collection, Aurora, CO.
- The clinical presentation of an ulcer in an older patient with known atherosclerotic disease and/or diabetes mellitus should trigger consideration of an arterial ulcer. This concern is augmented when the ulcer appears punched out, when it lies on the lateral leg, or if there are other findings of peripheral artery disease (e.g., loss of hair, shiny skin appearance, purple-red toes).
- Arterial ulcers may be unilateral or bilateral.
- Arterial ulcers usually affect the distal leg and are more likely to affect the lateral leg than stasis ulcers.
- Distal pulses may be diminished or absent.
- Chronic arterial insufficiency may lead to hair loss and thinned skin in the affected extremity.
- The toes may be purple-red due to vascular insufficiency.
- Arterial ulcers tend to have a more punched-out quality and are deeper than stasis ulcers.
- Arterial ulcers are often painful. The pain may be relieved by keeping the extremity below the level of the heart. Patients may also complain of claudication.
Imaging Studies
- Doppler ultrasonographic studies provide a noninvasive means to assess distal blood flow.
- Routine x-rays are rarely helpful in establishing the diagnosis but may be useful in excluding osteomyelitis in deep ulcers that overlie bone.
Differential Diagnosis
- Arterial ulcers
- Cholesterol emboli
- Dysproteinemias (e.g., cryoglobulinemia, cold agglutinin disease)
- Hydroxyurea ulcers
- Infectious ulcers
- Livedoid vasculopathy
- Necrobiosis lipoidica
- Neoplastic ulcers
- Neuropathic ulcers
- Pyoderma gangrenosum
- Red blood cell disorders (e.g., sickle cell anemia, thalassemia)
- Stasis (venous) ulcers
- Vasculitis (various types)
Treatment
Approach to Treatment
- The most important immediate treatment is referral to a vascular surgeon for consideration of bypass grafting, angioplasty (with or without stent placement), and atherectomy.
- Treatment of predisposing factors, such as optimizing diabetes management, smoking cessation, and hypertension treatment and/or hyperlipidemia therapy, may slow progression of the disease.
Nondrug and Supportive Care
- In contrast to stasis ulcers, compression should be avoided. Wound care is necessary, and skin grafts or artificial skin (e.g., Apligraf, Dermagraft) are helpful once granulation tissue has been achieved.
References
Gulati A, et al. Critical limb ischemia and its treatments: a review. J Cardiovasc Surg (Torino). 2015;56(5):775-85.