Differentials
Moisture-associated dermatitis
SIGNS / SYMPTOMS
Erythematous, macerated skin in an area that is exposed to chronic moisture.
INVESTIGATIONS
There are no differentiating tests; diagnosis is clinical.
Venous ulcers
SIGNS / SYMPTOMS
Commonly occur on lower legs near ankles; frequently accompanied by skin staining.
May be painful.
May be associated with lipodermatosclerosis, in which the lower part of the leg is hardened.
INVESTIGATIONS
Duplex ultrasound demonstrates retrograde or reversed flow; valve closure time >0.5 seconds indicative of venous insufficiency.
Arterial ulcers
SIGNS / SYMPTOMS
Found on feet, heels, or toes.
Surrounding skin often white and shiny.
Typically most painful in bed; pain sometimes relieved by having the legs dependent.
Ulcers often have a pale base and a punched-out appearance.
INVESTIGATIONS
Vascular assessment and an ankle brachial index ≤0.90.
Diabetic neuropathy
SIGNS / SYMPTOMS
Neuropathic diabetic ulcers are caused by pressure resulting often from ill-fitting shoes or failure to reposition limb due to impaired perception of pain. Ulcers commonly occur on the toes, the heels, or other parts of the foot.
INVESTIGATIONS
HbA1c may support poor glucose control.
Pyoderma gangrenosum
SIGNS / SYMPTOMS
Most often affects people in their 40s or 50s.
In approximately 50% of patients, it is associated with other conditions, including inflammatory bowel disease.
Characteristically, the edge of an ulcer is purple and undermined (tunneled) as it enlarges.
Ulcers are painful and most commonly occur on the legs. Unlike pressure ulcers, pyoderma gangrenosum ulcers start as a small discrete area and enlarge rapidly.
INVESTIGATIONS
There are no differentiating tests; diagnosis is clinical.
Osteomyelitis
SIGNS / SYMPTOMS
Typical symptoms are bone pain, tenderness, and swelling. May be a previous history of osteomyelitis, recent surgery, or penetrating injury. If bone is exposed in a suspected pressure ulcer, osteomyelitis should be excluded.[55]
INVESTIGATIONS
MRI is diagnostic.
Inflammatory markers are elevated.
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