When A Non-Healing Wound Has A Dermatologic Origin
- Volume 27 - Issue 2 - February 2014
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Venous stasis ulcerations are the most common wounds that occur on the medial aspect of the lower leg due to the course of the great saphenous vein. Venous stasis ulcerations are typically shallow/superficial, have an irregular border, often look weepy and wet, and are usually not painful. There is typically concomitant edema on the leg. In addition to the ulceration, the skin color is usually discolored purple or brown, superficial varicosities may be visible, there is often hardening (induration) of soft tissues, and accompanying dry scaling skin may be visible (venous stasis dermatitis).
One confirms the diagnosis with an ultrasound test to determine the degree of venous reflux. Treatment includes wound care and compression. Mechanical compression can occur with dressings, compression hosiery and/or lymphedema pumps. Surgical treatments may include endovenous laser treatment and/or skin grafting of the wound. Ultimately, one needs to address the swelling disorder or the risk of recurring ulcers is great.
A group of granulomatous diseases that include vasculitis can cause skin ulcerations. These conditions include Wegener’s granulomatosis and Churg-Strauss syndrome.
Wegener’s granulomatosis is also known as granulomatosis with polyangiitis. Patients with this syndrome typically have kidney and lung disease. The main serological marker is anti-proteinase 3 antineutrophil cytoplasmic antibodies. This marker can aid in the diagnosis of Crohn’s disease and inflammatory bowel disease.
Churg-Strauss syndrome is also known as eosinophilic granulomatosis with polyangiitis. This is an autoimmune disorder in patients with atopy (allergic hypersensitivity). Symptoms include upper respiratory disorders including asthma and reactive airway disease. There may be history of hay fever, allergic rhinitis and sinusitis. Elevations of perinuclear anti-neutrophil cytoplasmic antibodies may be present in about 50 percent of the cases of Churg-Strauss syndrome.1 In a complete blood count with differential, the eosinophils will typically be 10 percent or higher whereas a normal differential of eosinophils should be between 1 and 4 percent.
Non-melanoma carcinomas may cause chronic wounds that do not respond to wound care. A common non-melanoma carcinoma affecting the skin is squamous cell carcinoma. Carcinomas are skin cancers that are typically slow growing and affect sun-exposed areas. Sites of skin that have been burned, scarred or ulcerated for a long period of time are susceptible to cancerous changes. Less common non-melanoma skin cancers include Kaposi’s sarcoma, which is common in patients with HIV infection or in otherwise healthy elderly males from Mediterranean ancestry. Also, primary cutaneous lymphoma (mycosis fungoides), which is a low-grade lymphoma, can be associated with ulcerations and tumors. One can confirm these conditions through biopsy and histodiagnosis.
Ulcerations of skin can occur from arterial insufficiency. Unlike venous stasis ulcers, arterial ulcers are painful and deeper. A classic arterial ulcer has a “punched out” appearance. Contrary to venous stasis wounds, these ulcers are more likely to be on the lateral side of the leg/ankle (or on the foot). The skin is usually cool to touch and other signs of peripheral arterial disease (such as loss of hair growth or pale color of skin surrounding the wound) are present. The skin may be thin, atrophic and shiny. Testing to rule out arterial insufficiency includes ankle-brachial index, Doppler studies and angiography.
Infectious diseases can also be the cause of the wound. Sporotrichosis is a fungal infection caused by Sporothrix schenckii. The fungus is ubiquitous throughout the world and is present in the soil. The organism is most commonly introduced through the skin by a rose thorn prick. The classic infection includes suppurating nodules along a lymphatic channel. A less common presentation is pulmonary sporotrichosis that disseminates to organs including skin to cause lesions.