**5. Differential diagnosis**

### **5.1. Arterial ulcers**

Arterial leg ulcers result from peripheral arterial occlusive disease. Arterial ulcers typically are round or punched out with a sharply demarcated border and extremely painful. A fibrous yellow base or necrotic eschar is commonly seen (**Figure 2**).

**Figure 2.** Arterial ulcer.

The surrounding skin is cool to the touch. These ulcers frequently occur at the tips of the toes and over the bony prominences. Associated findings are weak or nonexistent arteria dorsalis pedis pulse, hair loss, atrophic skin, dystrophic nails, the presence of claudication, or rest pain. The ABI of 0.5 or less indicates severe arterial disease [4, 40, 41].

### **5.2. Neuropathic ulcers**

**None: 0 Mild: 1 Moderate: 2 Severe: 3** 

<1 year

N/A Diameter >2 cm Diameter 2–6 cm Diameter >6 cm

2 Wears stockings most days

Not healed for <1 year

compliance: stockings

3 Full

Active ulcer number 0 1 2 ≥3

1 Intermittent use of stockings

0 Not used

Hoc Outcomes Working Group. J Vasc Surg 2010;52:1387–96.

**Table 2.** Revised venous clinical severity score (VCSS) system.

yellow base or necrotic eschar is commonly seen (**Figure 2**).

N/A <3 months >3 months but

Modified from Vasquez MA, Rabe E, McLafferty RB, Shortell CK, Marston WA, Gillespie D, et al. Revision of the venous clinical severity score: venous outcomes consensus statement: special communication of the American Venous Forum Ad

A VCSS may range from 0 to 30 [31, 33, 39]. A score of more than eight indicates the progression of venous problem. In addition, the VCSS has been shown to be useful to evaluate the response

Arterial leg ulcers result from peripheral arterial occlusive disease. Arterial ulcers typically are round or punched out with a sharply demarcated border and extremely painful. A fibrous

hypodermitis) Includes white atrophy and lipodermatosclerosis

286 Wound Healing - New insights into Ancient Challenges

Active ulcer duration (longest active)

Active ulcer size (largest active)

Use of compression

to treatment.

**5.1. Arterial ulcers**

**Figure 2.** Arterial ulcer.

**5. Differential diagnosis**

therapy

Neuropathic ulcers are more common in patients with diabetes mellitus (DM). Trauma and/or pressures can cause wounding and ulcer formation in patients with neuropathy [41– 43]. These ulcers usually tend to be on the plantar surface of the foot. An abnormal, thickened callus develops at pressure areas, with ultimate disrupt of the tissue resulting in ulcer forma‐ tion (**Figure 3**).

**Figure 3.** Diabetic neuropathic foot ulcer.

### **5.3. Pressure ulcers**

Pressure ulcers mostly occur in patients with limited mobility. These ulcers can start to develop when soft tissue is compressed for a prolonged period of time. The main risky sites are the heel of the foot, malleoli, and sacral and trochanter areas [4, 44].

### **5.4. Hypertensive leg ulcer (Ulcus Cruris Hypertonicum Martorell)**

Hypertensive leg ulcers are extremely painful and commonly located on the distal portion of the lower leg above the lateral malleolus. These ulcers are seen in patients with prolonged, severe, or poorly controlled hypertension [41, 42]. The ulceration is secondary to tissue ischemia caused by increased vascular resistance.

### **5.5. Mixed ulcer**

Patients with mixed etiology ulcers have combined venous and arterial disease. Often further complicating factors such as DM, rheumatoid arthritis (RA), or lymphedema also exist [42].

### **5.6. Pyoderma gangrenosum**

Pyoderma gangrenosum is a neutrophilic dermatosis. Clinically it starts with sterile pustules that rapidly progress and turn into painful ulcers with purplish‐blue, undermined borders [42, 45]. It may be associated with inflammatory bowel disease, rheumatic, or myeloproliferative disorders [8, 12] (**Figure 4**).

**Figure 4.** Pyoderma gangrenosum.

**Figure 5.** Livedoid vasculopathy and tiny ulcerations.

### **5.7. Vasculitis**

Cutaneous vasculitis may present as palpable purpura, urticaria, nodule, bullae, livedo reticularis, necrotic areas, or skin ulceration. Vasculitic leg ulcers are often painful, multilocular and, surrounded by livid erythema and purpura (**Figure 5**). The different types of vasculitis that can cause cutaneous ulceration include small vessel vasculitis such as leukocytoclastic vasculitis, medium‐sized vessel vasculitis such as polyarteritis nodosa, microscopic polyan‐ giitis, and Wegener granulomatosis [41, 46]. Routine blood work, sedimentation, antineutro‐ phil cytoplasmic antibody (ANCA), urinalysis, chest X‐ray, and multiple skin biopsies should be done.

Livedoid vasculopathy (LV) is characterized by irregularly shaped, recurrent perimalleolar painful ulcers overlying areas of purpura. LV typically has three phases including livedo racemosa, ulcerations, and atrophie blanche [41, 42] (**Figure 5**).
