Basic approach to inflammatory ulcers

Abstract

Cutaneous ulcers are a difficult problem. A multidisciplinary approach is often adapted in caring for patients with nonhealing wounds. Internists, surgeons, dermatologists, and nurses must work together to provide a patient with the most comprehensive care possible. Dermatologists are consulted for a number of reasons, particularly if the ulcers are secondary to an inflammatory process. In this discussion, we describe a basic and useful approach to the diagnosis and management of inflammatory ulcers. The spectrum of these conditions is wide, ranging from vasculitis, to pyoderma gangrenosum, to ulcers resulting from the antiphospholipid syndrome and cryoprecipitates. The present authors will emphasize that the approach needs to be all-encompassing, and not focused on the ulceration alone. Certain clues are critical to diagnosis. The management, whereas often difficult, can be very rewarding.

Leg ulcers in antiphospholipid syndrome secondary to systemic lupus erythematosus treated with intravenous immunoglobulin

“…7,8 It is known that 30 to 50% of the patients with systemic lupus erythematosus will develop APS. Our patient has developed APS after 18 years of the diagnosis of SLE.…”

Connective tissue ulcers

“…1,3 Toxic effects of medications include use of corticosteroids that cause skin atrophy where minor trauma leads to ulceration. 2 RA patients can be debilitated from their disease and bedridden making them prone to pressure ulcers.…”

“…Nail fold capillaroscopy shows capillary dropout and tortuous blood vessels. 2,3 ENREF 9 Patients with systemic sclerosis may have serious and life threatening systemic complications affecting the lungs, GI tract, heart, and kidneys. The systemic complications highlight the need for a multidisciplinary approach.…”

“…However, many systemic diseases are associated with the development of PG, including inflammatory bowel disease, myeloproliferative disease, arthritis, or monoclonal IgA gammopathy. 3 In addition, many patients with CTD have ulcerations consistent with PG. The typical PG ulcer has been reported to start as a papule, pustule, or vesicle, which rapidly ulcerates.…”

“…2 This is why a complete history and physical exam including extensive review of systems, family history, and current and relevant past medications is imperative for diagnosis and management. 3 Having a CTD does not mean that a patient cannot have other concomitant vascular/neuropathic insufficiency like venous or pressure ulcers. This causes confusion because there is overlap.…”