Vascular Dermatoses - Ulceration on Lower Extremity - Case of the Week
Try this case and test your knowledge of vascular dermatoses.
A 54-year-old man with a history of obesity, diabetes mellitus, and hypertension has an ulceration on his right lower extremity after minor trauma (see Figure).
He has been applying topical bacitracin ointment, but he tells you that the ulceration is still not healing.
He has some pain during dressing changes.
You note a moderate amount of serous drainage.
He has no fever or chills.
What is the best management for this patient's ulceration?
The correct answer is:
Cover wound with dressing and compression therapy
Discuss why compression therapy is an essential treatment for venous stasis ulcers.
Covering the wound with dressings and applying compression therapy are keys to the treatment of venous stasis ulcers. No antibiotics are indicated in the absence of infection.
The patient has developed an ulceration following minor trauma.
The figure suggests the presence of venous insufficiency with the presence of venous stasis manifested as skin discoloration.
The ulcer is clean and does not seem to have any sloughing or infection.
The ulceration should be treated with dressing and compression therapy in the form of multilayer compression wraps or compression stockings.
Historically, leaving the wounds open to air was recommended, but using a dressing (ie. Unna boot) favors the healing by activation of the patient’s own enzymes.
Obtaining a culture is not indicated because there is no clinical evidence of infection.
Continued use of topical bacitracin may predispose the patient to contact dermatitis and is not indicated.
Checking up on an ankle-brachial index is pertinent if there is reason to be suspicious of arterial insufficiency.
Excisional debridement is recommended in the presence of sloughing or necrotic tissue.
Of interest is that ulcers on the lateral aspect of the ankle are more likely to be the result of arterial insufficiency while those on the medial aspect tend to be the result of venous insufficiency.
Alavi A, Sibbald RG, Phillips TJ, et al. What's new: management of venous leg ulcers: treating venous leg ulcers. J Am Acad Dermatol. 2016;74(4):643-664.
Michael JE, Maier M. Lower extremity ulcers. Vasc Med. 2016;21(2):174-176.
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