Typical or Atypical Leg Ulcers

Typical or Atypical Leg Ulcers

Statement of Clinical Problem:  Leg ulcers can present with an etiology of arterial, venous or mixed venous/arterial.  However long-standing, chronic non-healing leg ulcers that do not respond to conventional wound care should have biopsy to rule out malignancy.  Chronic wounds may develop into malignancy, most common squamous and basal cell carcinoma. A study by Synder, et al found 25% of wounds initially diagnosed as venous ulcers were found to be malignant. Accurate diagnosis of the etiology of  non-healing venous ulcers is critical in management of the wound.

Clinical Approach: Three cases are presented with lower extremity leg wounds that were unresponsive to appropriate wound care. All three cases have been treated in the past for venous insufficiency ulcers. The leg ulcers did not have typical presentation of venous insufficiency.

The goal was to identify etiology, control wound exudate and establish a treatment plan that provided a dressing that would not cause any pain on application or removal. Pain management was critical and wounds were treated with a topical Lidocaine along with systemic pain medication. Topical dressings used were contact layer dressing and foam, depending on the amount of exudate.

Conclusion: The clinician needs to be knowledgably in recognizing when a wound presents not as a typical etiology. These three cases needed to have wound biopsies performed to determine diagnosis and treatment. Most basal cell or squamous cell carcinomas that resemble chronic wounds have been found to be present many months and possibly years. Many times the clinician has to base their accurate assessment on providing appropriate interventions and be a strong advocate to have follow-up with a physician that will biopsy and offer appropriate treatments based on the results of the biopsy.