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Common problems with uncommon causes
- seemab ashraff (12 March 2006)
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Skin necrosis and coagulation factor abnormalities
- Michael Makris, Alexander Gatt, Joost J. van Veen (14 March 2006)
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Skin ulceration as another uncommon yet important presentation of malignant melanoma
- Candice Chan (17 March 2006)
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Calciphylaxis and ulceration
- Katherine A Finucane (10 May 2006)
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seemab ashraff, SHO Plastic and Reconstructive surgery Queen Victoria Hospital, East Grinstead, RH19 3DZ
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Treatment of ulcers is 'bread and butter' for the plastic surgeon. I found this article particularly interesting. It high-lighted to me the importance of thinking laterally when dealing with a common every day problem and remembering the more unusual causes. Next time I review a patient with a chronic non-healing ulcer, I will consider carefully the underlying cause. Competing interests: None declared |
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Michael Makris, Reader in Haemostasis and Thrombosis Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Glossop Road, Sheffield, S1, Alexander Gatt, Joost J. van Veen
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Editor – In their article on uncommon causes of ulceration, Patel and colleagues (1) include a table listing eight coagulation factors that are associated with skin necrosis. Whilst skin necrosis can be seen in association with coagulation factor deficiencies, this is very rare and is usually only seen with severe reduction in the concentration of protein C or protein S. This can occur due to inherited homozygous or acquired deficiency of proteins C/S following warfarin initiation or infection, most frequently due to meningococcal septicaemia (purpura fulminans). A very small number of single case reports suggesting an association with factor V Leiden/activated protein C resistance have been published (2,3), but this association remains unproven considering that 3-5% of the population of Europe and North America carry this mutation. We do not believe true skin necrosis has ever been described in antithrombin deficiency or in association with raised levels of homocysteine or prothrombin. Although heparin cofactor II and factor XII deficiency are also listed in the table, these two conditions are not known to be associated with any clinical phenotype even when completely absent from the circulation. Alexander Gatt, Clinical research fellow,
Sheffield Haemophilia and Thrombosis Centre,
Royal Hallamshire Hospital,
Glossop Road,
Sheffield, S10 2JF
References: 1. Patel GK, Grey JE, Harding KG. Uncommon causes of ulceration. BMJ 2006; 332:594-596 2. Makris M, Bardhan G, Preston FE. Warfarin induced skin necrosis associated with activated protein C resistance. Thromb Haemost 1996; 75:523-524 3. Freeman BD, Schmieg RE, McGrath S, Buchman TG, Zehnbauer BA. Factor V Leiden mutation in a patient with warfarin-associated skin necrosis. Surgery 2000; 127:595-6 Competing interests: None declared |
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Candice Chan, Foundation Year 1 Doctor Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA
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EDITOR –Patel et al pointed out cancers as unusual underlying causes of skin ulcers in their recent article1. He gave non-melanoma skin cancers and metastases as examples. I would also like to include malignant melanoma (MM) in addition to the above, after personally witnessed several cases of ulcerated lesions which turned out to be MM after diagnostic biopsy during my dermatology attachment. Although MM is less common than other skin cancers, it is the major cause of skin cancer mortality and is potentially curable if diagnosed and treated early2. Several authors reported detailed descriptions of MM that presented as atypical ulcers. Kong et al. reported six cases of acral melanoma presenting as chronic foot ulcers in both diabetic and non- diabetic patients3. Zellman reported a case of amelanotic ulcer presenting as an enlarging bleeding ulcer4. MM may be overlooked when they develop in atypical locations or present with unusual appearances such as vascular, non-pigmented, or ulcerated lesions which lack the classical clinical features of a changing mole (Asymmetry, Border irregularity, Colour variation, Diameter enlargement, and Elevated surface)5. The overall prognosis of atypical MM tends to be poorer than its pigmented counterparts. This is due to delayed diagnosis, and ulcerations being an indication of invasive disease with advanced TMN stage. Moreover, advanced MM is often resistant to current treatment2. This emphasise the importance of maintaining a high level of suspicion in order to recognise malignant causes of skin ulcers. Further studies and guidance may be helpful in determining the alarming features of ulcers suggestive of malignancies, which would prompt referral to dermatologists for diagnostic biopsy. 1. Patel GK, Grey JE, Harding KG. Uncommon causes of ulceration. BMJ 2006; 332:594-596 2. Roberts DLL, Anstrey AV, Barlow RJ, Cox NH. UK guidelines for the management of cutaneous melanoma. Br J Dermatol 2002:146:7 – 17. 3. Kong MF, Jogia R, Jackson S, Quinn M, McNally P, Daview M. Malignant melanoma presenting as a foot ulcer. Lancet 2005;366:1750. 4. Zellman GL, Houston MD. Amelanotic melanoma in a black man. J Am Acad Dermatol 1997;37:665 - 6. 5. Grant-Kels JM, Bason E, Grin CM. The misdiagnosis of malignant melanoma. Am Acad Dermatol 1998;40:539 - 48. Competing interests: None declared |
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Katherine A Finucane, Staff Grade in Dermatology UBHT, BS2 8HW
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Dear Sir, In this article about uncommon causes of ulceration, calciphylaxis ( calcific uraemic arteriolopathy,CUA) was cited as a cause. This does cause painful ulcers on the lower limbs and abdominal skin of patients with chronic kidney disease and diabetes. The histology of CUA shows calcification in the medial layer of the small arterioles with intimal hyperplasia, changes which can be seen in a wider area than the ulcerated area. These changes predispose to thrombosis in these vessels and the typical clinical picture. The deposition of the calcium in the walls is an organised process so does not cause calcium deposits at the site of the ulceration. Dystrophic calcification can occur at the site of ulceration which is probably what is shown in the illustration. Treatment is difficult with pain relief, local debridement and infection control being important, but there is high mortality. Competing interests: None declared |
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