A 92-year-old patient was referred to the Department of Dermatology, Venerology and Allergology, Lübeck Campus of the Schleswig-Holstein University Hospitals, with a provisional diagnosis of erysipelas.On admission to hospital, there was clear swelling of the left lower leg with slight distal reddening. Multiple small painful ulcers over the left medial malleolus and the Achilles tendon were noticeable (▶ Fig. 1). The pulses in the left foot were not palpable. The interdigital spaces on both feet were severely macerated. There were obvious striated excoriations consistent with scratch marks, mainly on the left thigh, and the skin appeared very dry, commensurate with the patient's age.Duplex ultrasound scanning of the venous system revealed haemodynamically relevant varicosity of the small saphenous vein (SSV) on the left. Sourcing of the venous reflux showed a clear relationship between the small saphenous varicose vein and the ulceration (1, 2).Examination of the arterial supply found biphasic signals over the femoral and popliteal arteries on both sides. Monophasic signals were present over the posterior tibial artery and the dorsalis pedis artery in the left leg. The ankle-brachial index was 0.88 on the right and 1.06 on the left. Relevant comorbiditiesThe patient had had a transient ischaemic attack (TIA) in the anterior cerebral artery territory two years previously. Following a thalamic bleed in 2008, he had left-sided ataxic hemiparesis, affecting the leg more than the arm, and he also had chronic axonal polyneuropathy. Additional medical conditions included diabetes managed on diet alone with normal HbA 1c levels, a thrombogenic aortic arch, hypertension, and depression controlled on medication. He was also taking platelet aggregation inhibitors.