Leg ulcer diagnosis and management

Effect of betablockers on the course of Martorell hypertensive ulcers: a retrospective study

Martorell hypertensive ulcer (MHU) represents a painful, difficult-to-handle condition associated with peri-pheral, subcutaneous arteriolosclerosis caused by chronic hypertensive disease. Betablockers are effective for and widely used to treat hypertensive disease but are reported to exacerbate peripheral vasoconstriction. The effect of betablockers on pre-existing arteriolosclerosis and the course of MHU is, however, unknown. A retrospective study to assess the effect of betablockers on the course and response to treatment of MHU was conducted. Clinical and histopathological data were collected of patients treated for MHU at the authors' institution between 2014 and 2023 and a side-by-side comparison was performed of patients taking betablockers or not. Analysis focused on MHU severity at presentation, analgesic use, response to therapeutic intervention, and alterations of cutaneous arterioles. The study reports significantly larger ulcers and more frequent use of opioids in patients taking betablockers, while no significant difference was observed in terms of MHU response to treatment. Significantly increased luminal obstruction of peripheral cutaneous arterioles was found in patients taking beta-blockers. Based on these data, betablockers may have a negative effect on the course of MHU and should be carefully assessed in patients with MHU.

Accurate Noninvasive Arterial Assessment of the Wounded Lower Limb: A Clinical Challenge for Wound Practitioners

Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds.

Martorell's Ulcer: Diagnostic and Therapeutic Challenge

Martorell's ulcer is an uncommon ischemic and extremely painful lesion located in the distal portion of the lower limb, resulting from severe systemic and poorly controlled hypertension. It is common in women between 50 and 70 years of age. The diagnosis is clinical and mostly belated, following exclusion of other causes. The response to treatment takes time and is unsatisfactory. A combination of several drugs associated with surgery may be required for wound healing. The authors present a case of Martorell's hypertensive ulcer, with emphasis on the diagnostic and therapeutic difficulties.

Uncommon leg ulcers in the lower extremity

OBJECTIVE

To determine the prevalence of uncommon ulcers, unrelated to venous or arterial etiology, in patients presenting to vascular clinics.

METHODS

This was a multicenter prospective study of consecutive patients presenting with lower extremity ulceration. The settings were university hospital outpatient centers and venous clinics. A total of 799 limbs in 710 patients with leg ulcers were evaluated. Patients with venous ulcer disease and with evidence of arterial disease with an ankle-brachial index less than 0.7 were excluded from the study. Out of 710 patients, 17 patients with a total of 21 limbs fit the criteria for inclusion. All limbs included in this study underwent physical examination, ankle-brachial index measurements, duplex ultrasonography, and skin biopsies.

RESULTS

The mean age of patients with uncommon ulcers was 65.6 years, and the mean duration was 5.5 years. A total of 2.1% of all leg ulcers seen were due to uncommon etiology unrelated to venous or arterial pathology. Most of these ulcers were located in the medial lower calf (n = 19). In six patients with ulcers, the histology did not reveal any specific cause; five had a neoplasia, three had chronic inflammation, two had sickle cell disease, two had vasculitis, one had rheumatoid arthritis, one had pyoderma gangrenosum, and one had ulcer due to hydroxyurea.

CONCLUSIONS

The prevalence of leg ulcers unrelated to arterial and venous disease that presented with signs and symptoms of chronic venous disease was 2.1%. Their etiology is variable, most often including vasculitis, neoplasia, metabolic disorders, infection, and other rare causes. Early identification of uncommon ulcers may facilitate timely and appropriate management.

Úlcera hipertensiva de Martorell: relato de caso

A úlcera hipertensiva de Martorell é úlcera isquêmica dolorosa de membro inferior, mais comum em mulheres, com dor desproporcional a seu tamanho e associada à hipertensão arterial sistêmica grave. É descrito um caso de homem negro, 56 anos, com hipertensão mal controlada de longa duração e lesão ulcerada extensa na panturrilha direita, cuja dor só foi aliviada com morfina, bloqueios peridurais e simpatectomia lombar. O diagnóstico baseou-se em hipertensão arterial, pulsos arteriais palpáveis, ausência de distúrbios venosos e dor intensa. O exame histopatológico de pele revelou alterações características, como espessamento da camada íntima da arteríola e estreitamento da luz.

Enzymatic versus autolytic debridement of chronic leg ulcers: a prospective randomised trial

OBJECTIVE

A randomised clinical trial (n = 42) compared the effectiveness of two approaches to debriding chronic leg ulcers: TenderWet 24, which is designed to support the autolytic degradation process, and Iruxol N (Santyl), an enzymatic treatment claimed to enhance the degradation process.

METHOD

Patients were randomly assigned to one of the two treatment groups for three weeks. Wounds were evaluated weekly for the amount of eschar/slough, the area of healthy granulation and the re-epithelialised area.

RESULTS

During days 1-14 slough within the groups was reduced by almost 19% for TenderWet 24 and by 9% for Iruxol N, followed by an increase of 26% and 10% respectively in granulation tissue. These effects were less accentuated during days 7-21. There was a further 11% improvement in tissue debridement for the TenderWet 24 group and a relapse (+9.1%) in the Iruxol N group.

CONCLUSION

Although TenderWet 24 appeared to be more efficient in a few cases, the general efficacy of the two products appeared to be almost the same as no statistically significant superiority of either product was found.

Understanding the underlying causes of chronic leg ulceration

Leg ulcers are debilitating and have a significant negative impact on patients' quality of life. It is particularly important to understand the underlying causes of leg ulcers that are described as 'slow to heal' to ensure they are managed effectively.

Venous leg ulcers

In 1837, Piorry, a French professor of medicine stated, "It is rather difficult to understand why the investigation of veins has been passed over almost in silence, while such a great diagnostic value has been attached to the investigation of arteries." Even today, our understanding of venous disease pales in comparison to our understanding of arterial disease. This is despite the fact that millions of Americans are afflicted with chronic venous insufficiency and hundreds of thousands suffer from debilitating lower extremity venous ulcers. A better understanding of the pathophysiology of venous disease is necessary to provide appropriate and efficient medical care for patients suffering from lower extremity venous ulcerations.