By Gary M. White, MD

An ulcer is an open area of the skin that will not heal. A shallow ulcer may just lack epidermis, whereas a deeper ulcer may penetrate into the dermis or subcutaneous tissue. Ulcers on the lower legs typically occur from poor circulation but other causes, e.g., pyoderma gangrenosum, must always be considered. A solitary ulcer anywhere may represent a neoplasm or infection. Multiple ulcers may occur in pyoderma gangrenosum or various infections. Any chronic ulcer should be biopsied, even ones on the lower leg, to rule out neoplasm or infection. Cultures for bacteria, fungus, and AFB are often done. The possibility that the patient is creating the ulcer(s) himself (factitial) should be entertained, especially if the ulcer has a geographic shape.

For lesions on the legs that appear due to poor circulation, a general workup can include ankle-brachial index, pedal pulse check, and vascular studies.

Ulcers Anywhere

Malignancy (e.g., basal cell carcinoma, squamous cell carcinoma). Here is a basal cell carcinoma x 2 years on the foot, thought to be a stasis ulcer.
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Factitial Ulcer

Pyoderma Gangrenosum
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Leishmaniasis. Several ulcers developed on the arms of this man 3 months after a trip to Central America.
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Metastatic Crohn's Disease

Leg Ulcers

Arterial Ulcer

Buruli Ulcer

Necrobiosis Lipoidica
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Prolidase Deficiency.

Antiphospholipid Antibody Syndrome

Cryoglobulinemia. Purpura of the legs, cutaneous ulcers, and livedo reticularis. [Clinical and Developmental Immunology Volume 2012 (2012), 11 pages].

Felty Syndrome. The term Felty syndrome has been used to describe the patient with rheumatoid arthritis with leukopenia and splenomegaly. These patients may develop leg ulcers.

Ecthyma. The ulcers of ecthyma tend to be dry, crusted, and on the lower legs.
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Sarcoidosis. Sarcoidosis may rarely present with leg ulcers [AD 1987;123;1531].

Sickle Cell Disease

Stasis Ulcer
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Livedoid Vasculopathy
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Hydroxyurea. Various skin conditions may occur during therapy with hydroxyurea including chronic leg ulcers.

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Klinefelter Syndrome. "Leg Ulcers Associated with Positive Lupus Anticoagulant in Two Cases of Klinefelter’s Syndrome" [Acta Dermato-Venereologica 2011;91;90-1 ].

Secondary Syphilis presenting as multiple ulcers for 3 weeks in an HIV positive man [Dermatology Online Journal 21(3)].

Other causes include infectious (e.g., syphilitic gumma, deep fungal infection), hematopoietic (e.g., cryofibrinogenemia and thalassemia), autoimmune (e.g., rheumatoid arthritis, systemic lupus erythematosus, scleroderma, dermatomyositis).


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