Ulcerated lower limbBMJ 2000; 320 doi: http://dx.doi.org/10.1136/bmj.320.7249.1589 (Published 10 June 2000) Cite this as: BMJ 2000;320:1589
- Nick J M London,
- Richard Donnelly
Ulceration of the lower limb affects 1% of the adult population and 3.6% of people older than 65 years. Leg ulcers are debilitating and painful and greatly reduce patients' quality of life. Ulcer healing has been shown to restore quality of life. Lower limb ulceration tends to be recurrent, and the total annual cost of leg ulceration to the NHS has been estimated at £400m.
Causes of lower limb ulceration
Mixed venous-arterial disease
Obesity or immobility
Necrobiosis lipoidica diabetecorum
Venous disease, arterial disease, and neuropathy cause over 90% of lower limb ulcers. It is useful to divide leg ulcers into those occurring in the gaiter area and those occurring in the forefoot because the aetiologies in these two sites are different. At least two aetiological factors can be identified in one third of all lower limb ulcers.
Venous ulcers most commonly occur above the medial or lateral malleoli. Arterial ulcers often affect the toes or shin or occur over pressure points. Neuropathic ulcers tend to occur on the sole of the foot or over pressure points. Apart from necrobiosis lipoidica, diabetes is not a primary cause of ulceration but often leads to ulceration through neuropathy or ischaemia, or both. The possibility of malignancy, particularly in ulcers that fail to start healing after adequate treatment, should always be borne in mind. The commonest malignancies are basal cell carcinoma, squamous cell carcinoma, and melanoma.
Patients with reduced mobility or obesity may develop ulceration in the gaiter area because of venous …