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  1. Girish K Patel, research fellow in wound healing and honorary clinical tutor in dermatology,
  2. Joseph E Grey,
  3. Keith G Harding
  1. Cardiff University and Cardiff and Vale NHS Trust

    This article describes some of the many rare causes of ulceration. Rare causes that are more common in developing countries—such as leprosy, fungal infections, Buruli ulcer, and ulceration resulting from Kaposi sarcoma—are not covered here.

    Causes of ulceration, according to typical clinical presentation

    Inflammatory disorders

    Inflammatory disorders can lead to ulceration or impair healing directly or through the effect of medication used to treat the disorder; ulceration is a feature of many connective tissue diseases. For example, ulceration develops in up to 10% of patients with rheumatoid arthritis and is often painful. In addition to the underlying disease, impaired healing can result from anaemia, skin atrophy, dependent oedema, deformity, neuropathy, microvascular disease, local factors, or the toxic effects of drugs used in its treatment. Other associated conditions such as vasculitis or pyoderma gangrenosum may also lead to ulceration.


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    Rheumatoid arthritis on dorsum of foot with exposed tendon, and over medial malleolus; such ulcers have a smooth, irregular margin

    Ulceration in rheumatoid arthritis is usually of rapid onset or enlargement, associated with pain (not relieved by raising or lowering the leg), fever, malaise, arthralgia, and myalgia. The ulcer may be multifocal and/or have an atypical location, tender margin, and/or a violaceous or erythematous inflammatory border.


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    Pyoderma gangrenosum over posterior gaiter area of leg (note also allergy to dressing on surrounding skin

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    Connective tissue disease associated with ulceration

    Pyoderma gangrenosum

    Pyoderma gangrenosum is characterised by the appearance of lesions at the site of trauma (for example, venepuncture). Surgical debridement of pyoderma gangrenosum often leads to a worsening of the ulceration. The diagnosis of pyoderma gangrenosum is primarily clinical but may be associated with specific features on histology. The patient often has a history of a painful sterile pustule or nodule with surrounding erythema, which eventually ruptures and ulcerates. The ulcer has a characteristic erythematous or violaceous …

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