DermatologyTier 1Disease (DEADMAN)

Skin ulcers - arterial

Description

Ulceration from critical tissue ischaemia due to peripheral arterial disease - punched-out, well-defined edge, deep, pale/necrotic base, minimal exudate
Classic sites: distal - toes, heels, lateral malleolus, pressure points - contrast with the gaiter/medial malleolar distribution of venous ulcers
Severely painful, classically worse with leg elevation and relieved by dependency (hanging leg over the bed) - opposite pattern to venous disease

Peripheral arterial disease prevalence rises steeply with age; risk factors - smoking, diabetes, hypertension, dyslipidaemia, established atherosclerotic disease elsewhere (IHD, stroke)
Second commonest cause of chronic leg ulceration after venous disease, but far higher amputation/mortality risk if unrecognised

Atherosclerotic arterial occlusion -> critical limb ischaemia -> tissue hypoxia -> minor trauma fails to heal, or spontaneous ischaemic necrosis at pressure points
Same systemic atherosclerotic process as coronary/cerebrovascular disease - an arterial ulcer is a marker of systemic vascular risk, not an isolated leg problem
Diabetes compounds arterial disease with microvascular and neuropathic contributions (see diabetic ulcers for that overlap)

Clinical

Cold peripheries, absent/weak pulses, prolonged capillary refill, dependent rubor with pallor on elevation, hair loss/shiny atrophic skin on the affected limb
Ulcer - punched-out, well-demarcated, pale/grey/necrotic base, painful, minimal granulation

Investigations

ABPI - the key test
- <0.9 - arterial disease present
- <0.5 or absolute ankle pressure <50mmHg - critical limb ischaemia, urgent vascular referral
- >1.3 (falsely elevated) - suspect calcified, non-compressible vessels (diabetes, CKD) - use toe-brachial index instead, as toe vessels calcify less
Arterial duplex ultrasound, CT/MR angiography to define the lesion before revascularisation

A. Confirm arterial status before any compression

Compression therapy is contraindicated if ABPI <0.8 (and used cautiously with modified low-pressure regimens even at borderline values) - unlike venous ulcers where compression is first-line

B. Revascularisation - the definitive treatment

Angioplasty +/- stenting or surgical bypass depending on lesion pattern/distribution - restoring perfusion is required for healing, wound care alone will not heal a critically ischaemic ulcer
Urgent vascular surgery referral for critical limb ischaemia (rest pain, ABPI <0.5, tissue loss)

C. Risk factor modification - as for any atherosclerotic disease

Smoking cessation (single most impactful modifiable factor), statin, antiplatelet therapy, BP and glycaemic control
Supervised exercise programs for claudication where limb is not critically ischaemic

D. Local wound care - adjunct only, not curative alone

Gentle debridement of non-viable tissue (avoid aggressive debridement of a poorly perfused wound), infection control, protect from trauma/pressure
Avoid tight/occlusive dressings and compression until revascularised

Smoking, diabetes, hypertension, dyslipidaemia
Coexistent coronary artery disease, cerebrovascular disease - shared atherosclerotic burden
Diabetic foot disease - mixed arterial/neuropathic ulceration common, requires assessment of both components

Without revascularisation - poor healing potential, high risk of progression to gangrene and limb amputation
Presence of an arterial ulcer signals significant systemic cardiovascular risk - associated with elevated mortality from MI/stroke, not just limb-related morbidity
Successful revascularisation substantially improves healing rates and limb salvage
Secondary infection in an ischaemic ulcer can progress rapidly given poor tissue perfusion/immune access - low threshold for escalation

6 more sections, plus exam facts

Premium unlocks every note across every specialty, and the full exam fact library behind it.