Miscellaneous Ulcers

Ulcers of Miscellaneous Causes

We've discussed arterial ulcers, venous ulcers,

pressure ulcers, and neuropathic ulcers on other

pages, but ulcers can have a variety of other causes

as well.

We'll cover a number of other possible causes of

ulcerations here.

Iatrogenic wounds

Doctors and nurses are usually involved in the treatment of wounds. So it may be surprising that one the most common of the miscellaneous causes are iatrogenic ulcerations. In other words, these ulcers are caused by the medical staff, itself.

This could be the physician ('Iatro' is Greek for physician, 'genic' means produced), the nurse, another member of the staff or the institution. The most common way a wound would be caused by a physician is following surgery.

This may be purposeful--where the foot was left open for some reason (like infection). He or she didn't want to seal an infection inside the body, so it was left open.

Or it may be an unintended result following surgery.

In the patient below, the forefoot was amputated following an aggressive infection. Because bacteria were still present in the wound, the wound was left open (below left). Closing it over would seal the bacteria inside , likely causing the infection to worsen. Closure was achieved through negative pressure wound therapy and local wound care, though it is usually closed later with sutures when the infection is resolved.

In this second example, an amputation of the 1st and 2nd toes and metatarsal was performed. The wound was left open and the patient discharged. Closure was achieved through local wound care, including debridement, dressings, compression and removal of pressure.

An example of an unintentional iatrogenic wound is found below. An amputation was performed but the 3rd metatarsal was left too long (proud) relative to the 4th and 5th metatarsals. Ambulation then created a wound on that longer bone. You can see the black, circular shadow overlying the bone on the x-ray corresponding to the ulcer on the lower right. This is a good example of how biomechanics is related to wound formation.

Note the black halo over the 3rd metatarsal in the x-ray (below left) corresponding to the ulcer (below right). Also note the zig-zag line between the 1st and 2nd metatarsals indicted below left by the yellow arrow. This is an artery, normally invisible on x-ray. However, the atherosclerosis (plaque built up in one of the major arteries to the foot) makes it visible. Its visibility suggests significant vascular disease.

Inflammatory diseases (vasculitis, lupus, scleroderma, gout, other rheumatological conditions)

Ulcerations can develop from a variety of inflammatory conditions, particularly if the patient is using systemic steroids that can weaken the skin.

The patient below was suffering from gout--a condition where urate crystals are deposited in the cooler parts of the body, most commonly the foot, which often causes pain. These deposits are called "tophi." Gout is characterized by significant episodic pain and periods of no pain.

Below we see two examples of an enlarged great toe joint as a result of these tophaceous deposits. (The great toe joint is a very common location of gout. When gout attacks the great toe joint, it is called "podagra.") However, gout may affect a variety of other foot and leg joints.

Below right you see two examples of ulcers through which gouty crystals are being extruded through the skin, in a white, runny consistency similar to cottage cheese.

This discharge continued for several weeks. The ulcers were closed by local wound care combined with an anti-gout medication.

Below left we see a rheumatoid nodule creating a prominence on the weight-bearing portion of the foot. These lesions can be uncomfortable in stance and eventually create an ulceration (below right--a different patient). Sometimes ulcers in this population are associated with steroid use, prescribed for the treatment of rheumatoid arthritis or a similar inflammatory arthritis, but which tends to weaken the skin.

Scleroderma and lupus are other examples.

Neoplasms

Neoplasms (tumours), both benign and malignant can create ulcerations.

Case presentations: Below left is an ulcerated malignant melanoma that cost the patient his life. It was misdiagnosed and treated as a wart for over a year before it was biopsied.

Below center is a benign vascular tumour that erupted through the skin to create an ulcer. It was removed surgically (below right).

Below left we see large, but benign fatty tumor (lipoma). Shoe pressure created an ulcer on the top of the ankle, precipitating removal of the tumour. This too was removed surgically (below right, at 2 months).

Infection

More often than not, ulcers develop first, then become infected. But infections, too, can lead to ulcerations. In the first example (below left), a rapidly-advancing bacterial infection created its own exit route in the arch, creating an ulcer. In the example below right, a bacterial meningitis (an infection involving the brain) created ischemia (loss of blood flow) to the digits, resulting in ulcerative gangrene. Leprosy, not seen much in North America, is another example of an infection that was once a common cause of ulceration.

Inappropriate Footwear

Shoes, boots, and orthopedic appliances
like orthotics can sometimes cause ulcerations,
too.

To the right we see a wound in an uncommon

location.

With the shoe on, the cause of the ulcer
becomes more clear.

Socks act as a barrier to friction and may
have prevented this ulceration. This is

particularly true in neuropathic patients

and those with fragile skin.

Below is an ulcer created from orthotic purchased from a local shoe store that sells orthotics. The orthotic was made with a metatarsal pad (like the one pictured below center). However, it was inappropriate in this foot with very poor circulation, and the pad was placed in the wrong area. It created the ulcer you see below. This patient had insufficient blood supply to heal from the wound and passed away from the wound.

Trauma

Trauma can also cause ulcerations. Most commonly, this is caused by a low-grade repetitive trauma or shear. This could be a result of a excessive walking causing a blister that ruptured, causing an ulcer (below left), or as a result of a contracted toe (below right) in a neuropathic foot. This could be classified as a neuropathic ulcer as well.

However, ulcers can also result from a more major trauma

like a motor vehicle accident, lawnmower accident, etc.

Lymphedema

Lymphedema refers to swelling caused by damage to the

lymphatic system. Lymph vessels pick up extra fluid

accumulating in your tissues and deliver it back to your

circulatory system. It also acts as part of your immune

system.

When the lymphatic system is blocked or not functioning

properly (right), proteins that are normally filtered out,

remain in the interstitial fluid (the spaces between the cells.

These interstitial proteins keep the fluid in this space, so

unlike venous edema, lymphedema doesn't "pit" with

compression from a finger or thumb (below).

The "pitting" edema (below) commonly seen in swelling
caused by venous problems is not typically found in swelling
caused by lymphedema.

Lymphedema is most commonly caused by damage to the lymph nodes in cancer surgery and infection.

The massive swelling that accompanies lymphedema can cause ulcers to form, as it does with venous ulcers.

Spinal Cord Injuries

Spinal injuries that result in damage to the sensory nerves of the lower extremity can also cause ulceration. Because of an injury to the first sacral nerve in the spine, the patient shown here had completely normal sensation everywhere in the foot except for the area indicated by the dashed lines around the wound (below left).

It looks uninfected from the bottom, but you can see the infection spreading up the leg in the photo below.

As with neuropathic wounds, the primary treatment is directed towards removing necrotic tissue, a proper dressing, and offloading.

Self Induced (Factitious)

Self-induced ulcerations are relatively common.

Some of the most common are those who accidentally

injure themselves by trying to "doctor" themselves.

Often this occurs while trying to remove calluses or

corns, or by trying to cut out an ingrown nail.

The patient shown to the right had been putting acid

on a wart. She kept applying it even after the wart

was gone, convinced it was still there. This lesion

extended down to the connective tissue covering the

bone.

Another way patients can create their own wounds is

through an obsessive-compulsive disorder.

The patient shown to the right has an obsession to pull

off his own toenails (onychotillomania), which has caused

him several infections.

He also has an obsession to incessantly pick at his own

skin (dermatotillomania). He caused the ulcer on the

side of the large toe seen in this photograph, and was

in the midst a course of IV antibiotics for a bone infection

(osteomyelitis) because of the wound.

This list of causes of ulcers is not exhaustive.

Other examples of conditions that may cause ulcers in the lower extremity include haematological disorders like sickle cell anemia and thrombocytosis, dysproteinaemias like amyloidosis and cryoglobulinemia, congenital insensitivity to pain, immunodeficiencies like HIV and those on immunosuppressant medication, pyoderma gangrenosum, and radiation damage.