Severe peripheral artery disease (PAD) is the predominant cause of ischemic ulcerations involving the lower extremities. PAD-associated ulcerations are typically distally located involving the feet, toes, and sometimes the calves. In contradistinction, atypical ischemic ulcerations of the lower extremity are often nonatherosclerotic in etiology, involve the proximal leg (thigh/buttocks), can evolve despite palpable distal pulses, and may coexist with other cutaneous aberrations (e.g. macules, purpura, nodules, and livedo reticularis). A differential diagnosis of atypical ischemic ulcerations involving the legs is presented.