The patient is an 81 y.o. woman with a 4 year history of an ulcer of her right leg. She has received treatments from a variety of specialists during this time and the ulcer was unsuccessfully grafted ~ 3 months ago. The patient is an asthenic vegetarian but takes multivitamins and there is no evidence of anemia. Her arterial circulation is normal per doppler studies. She is taking doxycline because of purulence but a culture was not done.
O/E: There is a 12 x 8 shallow ulcer over the lower right leg. The foot is warm and a dorsalis pedis pulse was present. There is an early champagne bottle deformity and lymphedema of the affected leg..
Clinical Photos:
Impression: Large venous leg ulcer.
Discussion: The patient, who lives independently with her husband, has mild to moderate cognitive decline and does not seem overly concerned about the ulcer. The ulcer continues to advance in spite of medical attention. Without intensive care, it is unlikely that such a large ulcer will heal. Her case is presented for discussion and therapeutic suggestions.
References:
1. Alavi A et al. What’s new: Management of venous leg ulcers: Treating venous leg ulcers. J Am Acad Dermatol. 2016 Apr;74(4):643-64
2. Alavi A e.al. What's new: Management of venous leg ulcers: Approach to venous leg ulcers. J Am Acad Dermatol. 2016 Apr;74(4):627-40. Alavi A. Et al. J Am Acad Dermatol. 2016 Apr;74(4):627-40; quiz 641-2.
3. Compression bandages or stockings versus no compression for treating venous leg ulcer. Meta-AnalysisCochrane Database Systematic Reviews. 2021 Jul 26;7(7):CD013397. Free PMC article
R.S., Hawaii. I’d make sure the workup is complete. Obviously biopsy, full workup for lupus, Protein, C,S. etc. anticoagulants, atypical mycobacteria and deep fungal cultures, r/o squamous cell ca, vascular surgery workup, trial for 3 months of compression stocking, embolic phenomena. I’d start from scratch before labeling it pyoderma gangrenosum and putting the patient unnecessarily on immunosuppression. PG should be a diagnosis of exclusion and not a default diagnosis.
ReplyDeleteH.F., Malaysia. I recently had a similar patient. I would do a biopsy to make sure it is not Marjolin ulcer ( SCC). I think I will stop the doxycycline but do a culture instead.
ReplyDeleteNext proper wound care with hydrocyn solution, debide dead necrotic tissue, put on intrasite gel, elevate leg, and once clean put on a 4-layer compression bandage for 3-7 days repeatedly until wound recovers. Basic blood works and biochem. Daflon 1 gm bd may help. Really have to be persistent. May take several weeks / months to recover.
J.S. North Carolina: This is a long shot, but are you sure of the diagnosis with this patient? I had a similar patient at the VA when I was a first year derm resident. At least five years worth of derm residents had taken care of this fellow with a steadily enlarging huge leg ulcer. I took a biopsy of a leading edge of the ulcer - turned out the whole thing was an enormous untreated BCC!
ReplyDeleteJust a thought. A biopsy might help turn up an unconsidered diagnosis if this has not been done.
D.J. Hawaii: If biopsy is negative for skin cancer, then compression and elevation would
ReplyDeletebe the next step.
Non healing ulcers in an elderly without any identifiable pathology, many times do not heal because of slower circulation and so reduced oxygenation.
ReplyDeleteCalciphylaxis – without any possible pathology can occur and produce non healing ulcers.
Ultra violet light not only is a good sterilizer but also promotes wound healing and is safe given for limited period of time.
All dressings should be porous facilitating aeration.
A.A. Mayo Clinic: This is a venous leg ulcer and the management of venous leg ulcer was discussed in the JAAD CME that was referenced.
ReplyDeleteJust briefly, ordering venous hemodynamic study ,applying compression therapy ( glad standard) , if superficial venous system or perforators involved, referral for interventions such as laser , or surgical procedures,……