arterial ulcer

Etiology

• arterial insufficiency
• peripheral arterial disease

Clinical manifestations

• atrophic skin bordering ulcer
• pallor on elevation of extremity
• diminished pulses, cool skin
• relatively painful lesions
  • pain may worsen at night
  • pain may worsen with elevation of extremities
  • pain may lessen with hanging the foot over the edge of the bed
• punched-out necrotic ulcers with surrounding erythema
  • dry pale pink, gray or yellow wound bed
  • sharply demarcated borders with a dry wound base
  • often with eschar or necrosed tissue in the wound
  • generally no bleeding
• distribution
  • may appear random, but generally distal arterial supply
  • over pressure areas & over bony prominences
  • on digits
  • frequently on lateral aspect of ankle
• pretibial areas

* images

Diagnostic procedures

• diminished ankle/brachial index (< 0.5-0.6)

Differential diagnosis

• cholesterol embolization is suggested by infarction of the toes in association with livedo reticularis
• venous stasis ulcer (see for comparison)
  • occur most commonly near the medial malleolus
  • associated with signs of chronic venous insufficiency
  • often weep serous fluid
• neuropathic ulcer
  • secondary to repetitive trauma to the skin, typically in patients with diabetic peripheral neuropathy with reduced awareness of pressure or trauma to the skin
  • neuropathic ulcers in diabetics are painless, most common on the plantar surface of the feet, callus & foot deformity are common

Management

• avoid friction & pressure
  • application of compression may worsen ischemia & is absolutely contraindicated
• dressing
  • foam dressing
  • hydrogel
  • alginate dressing
  • absorptive wound filler
  • collagen-based dressing
  • gauze
  • do NOT use hydrocolloid dressing
  • do NOT moisten an arterial ulcer if no healing potential, leave dry
• do NOT debride ischemic arterial ulcer
• risk factor management
• measures to increase blood supply
  • limited evidence of benefit for cilostazol
• referral to vascular surgeon
  • revascularization may facilitate wound healing

More general terms

• cutaneous ulcer

Additional terms

• neuropathic ulcer
• peripheral arterial disease; peripheral artery atherosclerosis (PAD)
• pressure ulcer (decubitus ulcer, bedsore)
• venous stasis ulcer