Thursday, February 01, 2018

Mal Perforans Ulcer

The patient 74 year old divorcee who lives alone.  He is an insulin-dependent diabetic with peripheral neuropathy.  He has had a plantar ulcer for > 6 months that began after a callosity was pared down by a podiatrist.  He has been seen at a wound care clinic for six months where dressings are done.  He is afraid he may lose his foot.

O/E:  On the plantar aspect of the left foot, he has a clean. painless ulcer measuring about 1.4 cm in diameter.  There was a thick callosity the ulcer's periphery.  His pedal pulses are strong.

Clinical image:
Question:  How would you approach this ulcer?

The patient had an orthopedic procedure two months ago.  This was intended to  redistribute some of  the pressure on the ulcerated area.  It was quite successful.  He has some mild foot edema presently, but the ulcer has healed completely.  His A1C is normalizing, too.

Lu SH, McLaren AM. Wound healing outcomes in a diabetic foot ulcer outpatient clinic at an acute care hospital: a retrospective study. J Wound Care. 2017 Oct 1;26(Sup10):S4-S11
OBJECTIVE: Patients with diabetic foot ulcers (DFU) have an increased risk of lower extremity amputation. A retrospective chart review of patients with DFUs attending the Foot Treatment and Assessment chiropodist-led outpatient clinic at an inner-city academic hospital was conducted to determine wound healing outcomes and characteristics contributing to outcomes.
METHOD: We reviewed the complete clinical history of 279 patients with 332 DFUs spanning over a five-year period.
RESULTS: The mean age of patients was 61.5±12.5 years and most patients (83.5%) had one DFU. The majority of wounds (82.5%) were in the forefoot. Overall, 267/332 (80.5%) wounds healed. A greater proportion of wounds healed in the forefoot (82.5%) and midfoot (87.1%) than hindfoot (51.9%; p<0.001). Using a logistic regression model, palpable pedal pulse and use of a total contact cast were associated with better wound healing.
CONCLUSION: Our findings are the first to demonstrate the benefits of chiropodists leading an acute care outpatient clinic in the management of DFUs in Canada and delivers wound healing outcomes equivalent to or exceeding those previously published.



  1. If the patient lives anywhere near Danville, PA, have him seen by Fred Miller, the world authority on this topic. The hyperkeratosis should be carefully debrided and followed by appropriately designed orthotic shoes, all while keeping the wound clean with mupirocin.

  2. from Dr. Cheng Leng Ong, Malaysia:

    Thanks for sending me the case of the deep plantar ulcer in a diabetic.

    My plan of treatments will be as follows:-

    1. Improve the control of diabetes, without which the ulcer won’t heal, and the more messy the ulcer, the more difficult to control the diabetes. We need to break this vicious cycle by team working with a diabetologist.

    2. Explain the low risk of malignant change of this chronic ulcer, low risk because of short duration and innocent looking morphology. I will happily accept and document patient's decision to decline a biopsy. Happily because we don’t want to be blamed for setting off a chain of events in a diabetic food, starting with the biopsy, occasionally leading to an amputation!

    3. After much experience of treating chronic anaesthetic ulcer in Leprosy patients, which is similar except for diabetes being the cause in this patient, I will counsel the patient about the need of proper foot-wears, protective but not too hard to cause callosity, a stumbling block to the healing process. Patient must not walk too far and rough consciously, as the peripheral neuropathy will give no warning like pain from overdoing these.

    4. Nursing care of cleaning the ulcer and application of solcoceryl gel etc.

    5. Admission for rest to facilitate healing, an occasional help by surgeon to debride minimally when necessary.

    5. Pray.

  3. Medical/surgical approaches are purely ancillary. He needs a custom orthotic shoe which will completely offload pressure on the ulcer and surrounding blood supply.

  4. Bhushan KumarFebruary 08, 2018

    The hyperkeratotic rim will not allow the ulcer to heal. The rim has to be surgically removed with a fair amount of normal skin and then the wound will heal by secondary intention. We always give UVR therapy as well- as it in addition to sterilizing the wound- also promotes healing. The weight bearing can be allowed gradually.


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