Diagnosis
- In the case of ulcers of rare location, with irregular, raised or hyperpigmented borders, friable overgranulation and absence of response to compression therapy, an atypical cause must be suspected.
- -> Patients may also have concurrent arterial and/or venous insufficiency -> vascular evaluation is needed for every patient
- In patients or travellers from tropical areas, a wide biopsy for tissue cultures including atypical bacteria, mycobacteria and fungi should be taken.
- When suspecting Martorell and calciphylaxis ulcers, a wide and deep biopsy should be performed from the edges of the wound.
- Punch biopsies can be used if malignancy is suspected and should be repeated if the result is negative but suspicion is high.
- In the case of vasculitis, in addition to the biopsy specimen, a specimen for direct immunofluorescence (DIF) should be taken. For this, an acute lesion (<24 hours old) should be chosen -> +blood test with autoinmune profile.
Treatment
- The treatment of atypical wounds will be directed at their cause -> Once the aetiology has been confirmed, local treatment to promote healing is similar for all wounds, regardless of their cause.
- Regardless of the cause (trauma, surgery, vasculitis, PG…), if no contraindication exists, compression therapy, adapted to each patient, seems to be a good anti-gravity and anti-inflammatory treatment for any leg wound, always associated with anti-oedema measures (during rest, legs should be elevated as much as possible).
- The EWMA document ‘Atypical Wounds: Best Clinical Practices and Challenges‘ develops the different types of atypical wounds in more detail.
Types and characteristics of atypical wounds
EWMA document: Lower Leg Ulcer Diagnosis and Principles of Treatment
