Lower leg ulcer

Differential Diagnosis

Common Causes

	Venous	Arterial	Neuropathic
History	Prior DVT, stroke, or miscarriages Obesity, multiple pregnancies Pain on prolonged standing	Smoking Diabetes Dyslipidemia Claudication	Diabetes Other causes of a peripheral neuropathy
Location	Gaiter distribution Medial more than lateral malleolus	Pressure points Distal points, such as toes	Pressure points
Pain	Mild to moderate	Severe	None
Morphology	Shallow, with irregular borders	Punched-out, with necrotic eschar	Punched out
Skin	Venous stasis dermatitis and lipodermatosclerosis	Shiny, hairless atrophic skin	Callous surrounding the ulcer
Other findings	Varicose veins Peripheral edema	Weak/absent pulses Delayed cap refill Pallor on elevation (45º for 1 min)	Peripheral neuropathy

Uncommon Causes

• Trauma or burns
• Infection, including ecthyma (from Streptococcus pyogenes) and ecthyma gangrenosum (from Pseudomonas)
• Vasculopathy
  • Vasculitis
  • Livedoid vasculopathy
  • Thromboangiitis obliterans (Buerger disease)
  • Microvascular occlusion disorders: cryoglobulinemia, cholesterol embolism, oxalosis, calciphylaxis
  • Sickle cell disease
• Pyoderma gangrenosum
• Panniculitis
• Malignancy
• Drugs
• Brown recluse spider bite