Lower Extremity Ulcers

Ulcers are wounds or open sores that will not heal or keep returning. Ulcers may or may not be painful. The patient generally has a swollen leg and may feel burning or itching. There may also be a rash, redness, brown discoloration or dry, scaly skin.

The three most common types of leg and foot ulcers include:

1. Venous stasis ulcers
Venous ulcers are located below the knee and are primarily found on the inner part of the leg, just above the ankle.

The base of a venous ulcer is usually red. It may also be covered with yellow fibrous tissue or there may be a green or yellow discharge if the ulcer is infected. Fluid drainage can be significant with this type of ulcer.

The borders of a venous ulcer are usually irregularly shaped and the surrounding skin is often discolored and swollen. It may even feel warm or hot. The skin may appear shiny and tight, depending on the amount of edema (swelling). The skin may also have brown or purple discoloration about the lower leg, known as "stasis skin changes."

Venous stasis ulcers are common in patients who have a history of leg swelling, long standing varicose veins, or a history of blood clots in either the superficial or the deep veins of the legs. Ulcers may affect one or both legs.

Venous ulcers affect 500,000 to 600,000 people in the United States every year and account for 80 to 90% of all leg ulcers.

2. Arterial (ischemic)
Arterial ulcers are usually located on the feet and often occur on the heels, tips of toes, between the toes where the toes rub against one another or anywhere the bones may protrude and rub against bed sheets, socks or shoes. Arterial ulcers also occur commonly in the nail bed if the toenail cuts into the skin or if the patient has had recent aggressive toe nail trimming or an ingrown toenail removed.

The base of an arterial or ischemic ulcer usually does not bleed. It has a yellow, brown, gray, or blackened color. The borders and surrounding skin usually appear as though they have been punched out. If irritation or infection are present, there may or may not be swelling and redness around the ulcer base. There may also be redness on the entire foot when the leg is dangled; this redness often turns to a pale white/yellow color when the leg is elevated.

Arterial ulcers are typically very painful, especially at night. The patient may instinctively dangle his/her foot over the side of the bed to get pain relief. The patient usually has prior knowledge of poor circulation in their legs and may have an accompanying disorder.

3. Neurotrophic (diabetic)
Neurotrophic ulcers are usually located at increased pressure points on the bottom of the feet. However, neurotrophic ulcers related to trauma can occur anywhere on the foot. They occur primarily in people with diabetes although they can affect anyone who has an impaired sensation of the feet.

The base of the ulcer is variable, depending on the patient's circulation. It may appear pink/red or brown/black. The borders of the ulcer are punched out, while the surrounding skin is often calloused.

Neuropathy and peripheral artery disease often occur together in people who have diabetes. Nerve damage (neuropathy) in the feet can result in a loss of foot sensation and changes in the sweat-producing glands. As a result, a person may not feel the development of foot calluses or cracks, increasing the risk of injury or infection. Symptoms of neuropathy include tingling, numbness, burning or pain.

It is easy to understand why people with diabetes are more prone to foot ulcers than other patients. This is why people with diabetes need to inspect their feet and their shoes daily and wear appropriate footwear. People with diabetes should never walk barefoot.