Leg ulcers


– Leg ulcers are chronic losses of cutaneous tissue. They are common in tropical regions, resulting from varied aetiologies:
• vascular: venous and/or arterial insufficiency,
• bacterial: leprosy, Buruli ulcer (Mycobacterium ulcerans), phagedenic ulcer, yaws, syphilis,
• parasitic: dracunculiasis (Guinea-worm disease), leishmaniasis,
• metabolic: diabetes,
• traumatic: trauma is often a precipitating factor combined with another underlying cause/

– The history of the disease and a complete clinical examination (paying particular attention to the neurological examination to determine if there is a peripheral neuropathy caused by leprosy or diabetes) usually leads to an aetiological diagnosis.

– All ulcers may become complicated with either local or regional secondary infections (abscess, lymphadenopathy, adenitis, osteomyelitis, erysipela, pyodermitis), generalised infection (septicaemia), tetanus and after many years of evolution, skin cancer.

Daily local treatment

– Bathe the leg for 10 to 15 minutes in NaDCC or chloramine and rinse in boiled water.

– Remove any necrotic (black) and fibrinous (yellowish) tissue using compresses or excise the tissue with a scalpel.

– Apply:
• to a clean ulcer, with little discharge: 10% polyvidone iodine and vaseline;
• to a dirty ulcer, with little discharge: silver sulfadiazine;
• to an oozing ulcer: 10% polyvidone iodine alone;
• o multiple or extensive ulcers with no discharge: silver sulfadiazine (monitor for systemic adverse effects);
• to multiple or extensive oozing ulcers: diluted polyvidone iodine (1/4 of 10% polyvidone + 3/4 of 0.9% NaCl or clean water) for one minute then rinse with 0.9% NaCl or clean water to reduce the risk of transcutaneous iodine absorption.

– Cover with a dry sterile dressing.

Systemic treatment

– Treatment with analgesics in the event of pain: adapt the level and dosage to the individual (see Pain, Chapter 1).

– Give systemic antibiotics in case of:

• Secondary infection (see Bacterial skin infections, Chapter 4).

• Phagedenic ulcer (in the early stages, antibiotics may be useful. They are often ineffective in the chronic stages):
doxycycline PO (except in children under 8 years and pregnant or lactating women)
Children over 8 years: 4 mg/kg once daily
Adults: 200 mg once daily
or
metronidazole PO
Children: 10 mg/kg 3 times daily 
Adults: 500 mg 3 times daily
If after 7 days, antibiotherapy is effective, change to oral treatment by using phenoxymethylpenicillin PO in the same dosages (or continue the treatment with doxycycline or metronidazole as above). Treatment duration varies according to the clinical evolution.

– Treat the cause.

– Complementary therapy:
• Elevate the legs in cases of venous and/or lymphatic insufficiency.
• Tetanus prophylaxis if appropriate (see Tetanus, Chapter 7).
• Skin graft if the ulcer is extensive, clean, red and flat. Skin grafts are often necessary after surgical excision to heal phagedenic and Buruli ulcers.