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Miscellaneous dermatology

Leg ulceration key points test

Risk factors for venous ulceration include: # Diabetes mellitus # Hypertension #! Cellulitis #! Prior deep venous thrombosis Explanation: Chronic venous insufficiency is associated with prior deep venous thrombosis, prior cellulitis, incompetent (varicose) superficial or communicating veins, arterial fistulas and neuromuscular dysfunction. Risk factors for atherosclerosis include: #! Diabetes mellitus #! Hypertension # Cellulitis # Prior deep venous thrombosis Explanation: Risk factors for atherosclerosis include smoking, hyperlipidaemia, hypertension, diabetes mellitus, obesity and arterial disease elsewhere. Signs of venous insufficiency may include: # Ankle Brachial Pressure Index <0.8 #! Dermatitis affecting distal lower leg #! Lipodermatosclerosis # Livedo reticularis Explanation: Signs of venous insufficiency include oedema, pigmentation, stasis dermatitis, lipodermatosclerosis and dry thickened skin. Signs of arterial insufficiency may include: #! Ankle Brachial Pressure Index <0.8 # Dermatitis affecting distal lower leg # Lipodermatosclerosis #! Livedo reticularis Explanation: Signs of arterial insufficiency include pale, shiny, hairless skin, livedo reticularis and diminished or absent pulses. An ankle Brachial Pressure Index of under 0.8 indicates significant arterial disease. Which of the following does not cause arterial ulceration? * Systemic sclerosis *! Leprosy * Drug reaction to warfarin * Hyperviscosity syndrome Explanation: Arterial insufficiency causing ulceration is most often due to atherosclerosis but it may also be due to vasculitis, disseminated intravascular coagulation, cryoglobulinaemia, hyperviscosity syndrome, septic embolisation, aneurysms, coumarin-induced necrosis, connective tissue disease, external compression or entrapment. Leprosy causes neuropathic ulceration. Management of chronic venous ulceration should include: #! Graduated compression #! Avoidance of trauma to affected area #! Injection sclerotherapy #! Debridement of necrotic tissue Explanation: Management of chronic venous ulceration should include occlusive dressings, avoidance of trauma to affected area and compression. Sclerotherapy and/or surgery to varicose veins, treatment of dermatitis, systemic antibiotics and debridement may also be necessary. Management of arterial ulceration should include: # Graduated compression #! Avoidance of trauma to affected area # Injection sclerotherapy #! Debridement of necrotic tissue Explanation: Management of arterial ulceration should include stopping smoking, graduated exercise, correction of hyperlipidaemia and hypertension and analgesics. Vascular surgery may be required, including angioplasty, endarterectomy, bypass procedures and debridement or amputation as needed. Compression is contraindicated. Neuropathic ulcers are characterised by: #! Painless ulceration #! Occurrence at pressure points # Superficial bullae #! Callus formation on ulcer edges Explanation: Neuropathic ulcers may be painful or painless. Signs of neuropathy include reduced response to light touch and pain, and loss of reflexes. The ulcers affect pressure areas, most often on the feet, and are characteristically surrounded by callus. In the absence of neuropathy, decubitus ulcers are characterised by: # Painless ulceration #! Occurrence at pressure points #! Superficial bullae # Callus formation on ulcer edges Explanation: Decubitus ulcers most often arise on the sacrum, ischial tuberosities and greater trochanter. The ulcers are very painful unless there is also neuropathy. Stage 2 pressure ulcers are preceded by erythema and bullae. General management of ulcers should include: # Topical antibiotics #! Moist environment for wound healing #! Debridement of necrotic material # Vitamin-B replacement Explanation: Debridement is important to prevent wound infection and encourage the development of a healthy collagen matrix. Occlusion aids wound healing by providing a moist environment. Spreading infection should be treated with oral antibiotics; topical antibiotics are best avoided because of the risk of bacterial resistance and contact sensitization. Supplementary protein, iron, vitamin-c and zinc are only necessary if these are deficient.