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ACERCAMIENTO AL PACIENTE • Actualizado el 07 de febrero de 2022

Úlcera de las extremidades inferiores en adul-

tos: abordaje del paciente
Descripción general y recomendaciones

Fondo
● Las úlceras de las extremidades inferiores en adultos pueden aparecer en la pierna o el
pie y son más comunes en adultos mayores (mayores de 65 años), mujeres y pacientes
con antecedentes de enfermedad venosa, diabetes mellitus, hipertensión, hiperlipide-
mia, obesidad y tabaquismo.
● Las úlceras debidas a insuficiencia venosa son la causa más común de úlceras en las ex-
tremidades inferiores de la pierna.
● Es menos probable que la insuficiencia arterial periférica o la enfermedad arteriovenosa
mixta causen úlceras en las extremidades inferiores que la insuficiencia venosa, pero
son un diferencial importante ya que pueden implicar isquemia y pérdida inminentes de
tejido en las extremidades.
● Otras causas de úlcera en las extremidades inferiores incluyen úlcera por lesión por pre-
sión y neuropatía periférica (generalmente relacionada con la diabetes y ubicada en el
pie).
● Las causas menos comunes incluyen infecciones, cáncer, traumatismos, pioderma gan-
grenoso, calcifilaxis, vasculitis o trastornos reumatológicos, anemia de células falcifor-
mes y reacciones a medicamentos (necrosis inducida por warfarina).

Evaluación

● Las úlceras venosas se caracterizan por una úlcera que no cicatriza, típicamente en la
parte inferior de la pantorrilla y el maléolo medial en el contexto de edema crónico y sig-
nos de insuficiencia venosa , como venas varicosas o dermatitis por estasis.
● Las úlceras arteriales se caracterizan por una ulceración profunda con tejido necrótico,
generalmente ubicada en los puntos de presión , los dedos de los pies y los pies en pa-
cientes con enfermedad arterial periférica .
● Las úlceras del pie diabético suelen aparecer en la cara plantar del pie en áreas de trau-
matismos repetitivos y son consecuencia de neuropatía, presión y/o enfermedad arterial
periférica.
● Las úlceras por lesión por presión generalmente se ubican sobre prominencias óseas en
pacientes con movilidad limitada y presión prolongada en el área afectada.

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● En caso de sospecha de úlceras arteriales y cualquier otra úlcera que se sospeche esté
asociada con insuficiencia arterial, obtenga una prueba del índice tobillo-brazo o del ín-
dice dedo-brazo para identificar la enfermedad arterial periférica. ( Fuerte recomenda-
ción )
● En caso de sospecha de úlcera venosa, considere la posibilidad de realizar pruebas de
imágenes venosas para confirmar el diagnóstico.
● Evalúe todas las úlceras de las extremidades inferiores en adultos para detectar la pre-
sencia de infección. Los indicadores clínicos de infección incluyen dolor de nueva apari-
ción o aumento del dolor, mal olor, aumento reciente de tamaño, rotura de la herida,
falta de cicatrización, eritema y aumento de la temperatura del área circundante.
● En caso de sospecha de malignidad, pioderma gangrenoso, calcifilaxis u otra afección
sospechosa o si el diagnóstico es incierto después de una anamnesis y un examen físico
completos , considere la posibilidad de realizar una biopsia .

Gestión

● Evalúe las ulceraciones arteriales para detectar isquemia aguda de las extremidades o is-
quemia crítica de las extremidades , que pueden estar asociadas con un mayor riesgo de
muerte y amputación de las extremidades y pueden requerir tratamiento inmediato con
medicamentos o revascularización (consulte Manejo de la isquemia aguda y crítica de las
extremidades para obtener información adicional).
● El tratamiento inicial de las úlceras crónicas de las extremidades inferiores , incluidas las
úlceras vasculares, las úlceras por presión y las úlceras del pie diabético, generalmente
consiste en todo lo siguiente
⚬ desbridamiento de heridas
⚬ control de infección
⚬ aplicación de apósitos, incluida la terapia de compresión para úlceras venosas
⚬ descarga de presión localizada
⚬ manejo de las causas subyacentes
⚬ Reducción de factores de riesgo, como el tabaquismo y la hiperglucemia.
● Considere la posibilidad de consultar con especialistas en el cuidado de heridas en el
caso de heridas que no cicatrizan, especialistas en cirugía vascular en caso de sospecha
de isquemia y especialistas en enfermedades infecciosas en el caso de infecciones com-
plicadas o refractarias.
● Para el tratamiento de úlceras específicas y afecciones subyacentes, consulte también
⚬ Úlcera venosa
⚬ Enfermedad arterial periférica (EAP) de las extremidades inferiores
⚬ Úlcera del pie diabético
⚬ Infección del pie diabético
⚬ Lesión por presión de la piel y los tejidos blandos

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Related Topics
● Diabetic Foot Ulcer
● Diabetic Foot Infection
● Peripheral Artery Disease (PAD) of Lower Extremities
● Pyoderma Gangrenosum
● Pressure Injury of the Skin and Soft Tissue
● Venous Ulcer

General Information

Description

● lower extremity ulcers may appear on leg or foot 1

● most common causes include venous insufficiency, pressure injury ulcer, diabetic foot
ulcer, and peripheral arterial disease

Incidence/Prevalence

● estimated prevalence of lower extremity ulcers 1%-2% in adults in the United States 1
● about 70% of leg ulcers are due to venous disease and about 20% are due to arterial in-
sufficiency or mixed arteriovenous disease 1
● about 85% of foot ulcers are due to peripheral neuropathy and are often associated with
arterial disease 1

Differential Diagnosis

Venous Insufficiency and Ulcer

● venous ulcers due to venous insufficiency are most common type of lower extremity ul-
cer; about 70% of leg ulcers are due to venous disease 1
⚬ more common in women and patients ≥ 65 years old
⚬ risk factors include phlebitis, deep vein thrombosis, obesity, family history of chronic
venous disease, immobility, and prior leg injury
● chronic venous stasis with lower extremity edema accompanied by dull ache or pain, ec-
zematous changes, stasis dermatitis, or varicose veins generally precede venous
ulceration
● venous ulcers 2

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⚬ shallow exudative ulcers, typically over bony prominences such as the medial
malleolus
⚬ typically seen within surrounding skin changes of chronic venous insufficiency, such
as hyperpigmentation and firm edema ("brawny" edema)
⚬ typically nonhealing ≥ 4 weeks duration
● ulcer typically has a granulating base and presence of fibrin 2

● pedal pulses normal unless concomitant arterial disease 2

● see Venous Ulcer, Stasis Dermatitis, and Stasis Dermatitis for additional information

Arterial Ulcers

● about 20% of leg ulcers are due to peripheral artery disease (PAD) or mixed arteriove-
nous disease 1
⚬ more common in patients ≥ 65 years old or in patients aged 50-64 years with family
history of PAD or risk factors for atherosclerosis
⚬ cigarette smoking and diabetes markedly increased risk for PAD
⚬ patients may have symptoms of PAD, such as atypical leg pain or claudication
● arterial ulcers due to PAD are characterized by 2
⚬ deep ulcers usually on anterior on leg, distal dorsal foot, or toes
⚬ dry, fibrous base with poor granulation tissue and eschar
⚬ exposure of deep tissue, including tendons, may be present

● see Peripheral Artery Disease (PAD) of Lower Extremities for additional information

Pressure Ulcers

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● pressure ulcer is due to pressure injury of skin and soft tissue 2

⚬ typically affect patients with limited mobility and prolonged pressure to affected area
⚬ more common in patients > 65 years old
⚬ usually located over bony prominences
⚬ risk factors include excessive moisture, altered mental status, poor nutrition, comor-
bid conditions, such as diabetes mellitus and peripheral arterial disease (PAD), immu-
nodeficiency, or the use of corticosteroid therapy and smoking

● see Pressure Injury of the Skin and Soft Tissue for additional information

Neuropathic Foot Ulcers

● neuropathic ulcers are due to diabetic peripheral neuropathy or, less commonly, neuro-
pathic arthropathy due to another cause such as neurologic disease, tertiary syphilis,
drug adverse effects, or toxin exposure
● about 85% of foot ulcers are due to peripheral neuropathy and are often associated with
arterial disease 1
● diabetic neuropathic foot ulcers usually occur on plantar aspect of feet in areas of repeti-
tive trauma 2
⚬ risk factors include longer duration of diabetes (prevalence of peripheral neuropathy
increases as the duration of the disease increases), peripheral vascular disease, and
orthopedic abnormalities that alter biomechanics, resulting in areas of increased
pressure, such as bony foot deformities
⚬ diabetic foot ulcers present as an open sore or wound, but may be associated with
signs of neuropathy such as pain, burning, or numbness
⚬ common sites for diabetic foot ulcers include

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– distal tip of toes

– plantar aspect of toes
– plantar aspect of metatarsal heads
– heel
⚬ see Diabetic Foot Ulcer for additional information

● see also Diabetic Peripheral Neuropathy and Neuropathic Arthropathy

Less Common Causes of Lower Extremity Ulcers

● other causes of lower extremity ulcers

⚬ rheumatoid arthritis and Felty syndrome 3
⚬ osteomyelitis
⚬ calciphylaxis (calcific uremic arteriopathy) 2
⚬ sickle cell disease 2 ; see also Chronic Management of Sickle Cell Disease
● infectious diseases
⚬ bacterial
– impetigo
– ecthyma
– necrotizing fasciitis with clostridia, group A Streptococcus, Vibrio vulnificus
– tuberculosis
– atypical mycobacteria
– Buruli ulcer 4
– syphilitic gumma
⚬ viral
– chronic ulcerative herpes simplex
– cytomegalovirus ulcer
⚬ protozoal
– leishmaniasis
– amebiasis cutis
⚬ fungal
– Cryptococcus neoformans
– Coccidioides immitis
– blastomycosis
– histoplasmosis

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– sporotrichosis
– cryptococcosis
– aspergillosis
– penicilliosis
– zygomycosis
● ulcerative necrobiosis lipoidica 4
● cancer 2
⚬ cutaneous squamous cell carcinoma 3 ,4
⚬ basal cell carcinoma of the skin 3
⚬ cutaneous T-cell lymphoma 4
● systemic vasculitis
⚬ vasculitis 2 , including cryoglobulinemia, granulomatosis with polyangiitis
⚬ Behcet syndrome 4
⚬ polyarteritis nodosa 4
⚬ antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (see Granulomatosis
With Polyangiitis or Eosinophilic Granulomatosis With Polyangiitis) 4
⚬ cryoglobulinemic vasculitis (see Cryoglobulinemia Type I, Cryoglobulinemia Type II, or
Cryoglobulinemia Type III)
● exogenous tissue injury
⚬ spider or other arthropod bite
⚬ insect bite 4
⚬ factitious or self-induced ulcers 4
⚬ drug-induced tissue injury (may be associated with "track marks" or skin tracks of pos-
tinflammatory hyperpigmentation along sclerosed vessels) (see Opioid Overdose for
additional information)
● pyoderma gangrenosum 2
● drug reaction
⚬ warfarin-induced skin necrosis
⚬ hydroxyurea 3

History and Physical

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History
● ask about 1 ,2
⚬ duration of ulcer
⚬ any preceding skin lesions
⚬ any associated pain, fever, chills, or purulent discharge
⚬ any associated paraesthesias or numbness
⚬ any known trigger or trauma
⚬ comorbid medical conditions, especially diabetes, peripheral arterial disease, venous
insufficiency, hypertension, hyperlipidemia, rheumatologic conditions, vasculitic con-
ditions, cancer, and sickle cell disease
⚬ current and recent medications or drugs
⚬ history of deep vein thrombosis or phlebitis
● ask about symptoms of infection 5
⚬ infection may be a secondary infection of an underlying chronic ulcer or, less com-
monly, infection may be the primary cause of the lower extremity ulceration
⚬ ask about
– new onset pain, increasing pain, or altered pain in area of ulcer, including pain is
unrelated to any dressing change
– increase in exudate
– purulence
– malodor
– rapid increase in size of ulcer; increase of ≥ 20 % in size over < 4 weeks is conside-
red an increase in size
● ask about family history of similar condition 2
● determine smoking history, which is a risk factor for arterial insufficiency 1

Physical

General Physical

● assess for signs of systemic infection, such as fever, tachycardia, tachypnea, hypoten-
sion, or confusion/delirium (Clin Infect Dis 2014 Jul 15;59(2):e10)

Skin

● examine ulcer size, location, depth 1

⚬ shallow ulcers with flat margins, and slough and exudate at base appearing along lo-
wer calf suggest venous ulcers
⚬ deep, punched out ulcers with irregular margins and necrotic tissue at base and loca-
ted at pressure points, toes, and feet suggest arterial ulcers

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⚬ deep ulcers on the foot with a lack of sensation in surrounding area suggest neuro-
pathic diabetic ulcers
⚬ deep macerated ulcers over bony prominences, such as heel suggest pressure ulcers

● evaluate for signs of infection 5

⚬ malodor
⚬ purulent discharge
⚬ surrounding erythema and/or warmth, suggesting cellulitis
⚬ abscess
⚬ palpable crepitus
● evaluate for additional signs of venous insufficiency, such as
⚬ varicose veins
⚬ hyperpigmentation of skin
⚬ scaling or crusted plaques
⚬ edema
⚬ bilateral eczema and stasis dermatitis
⚬ telangiectasia, such as corona phlebectatica
⚬ lipodermatosclerosis (sharply demarcated hyperpigmentation and induration also ca-
lled "brawny" or "woody" induration); it may create an inverted "champagne bottle"
appearance of the lower extremity

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⚬ atrophie blanche (pale plaques of scar tissue)

⚬ see Stasis Dermatitis and Venous Ulcer for additional information
● evaluate for additional signs suggestive of peripheral arterial disease, such as
⚬ distal hair loss
⚬ trophic skin changes
⚬ hypertrophic nails
⚬ see Peripheral Artery Disease (PAD) of Lower Extremities for additional information
● evaluate for additional signs of diabetic foot ulcer, such as
⚬ areas of high pressure, such as corns and calluses
⚬ deformities that may predispose to areas of high pressure or impair healing, including
– neuropathic arthropathy (Charcot arthropathy) deformity
– claw or hammer toes
– bunions
⚬ see Diabetic Foot Ulcer for additional information
● evaluate for additional signs and sites of pressure injury
⚬ assess surrounding skin for erythema response, whether blanchable or
nonblanchable
⚬ look for eschar formation
⚬ see Pressure Injury of the Skin and Soft Tissue for additional information
Extremities

● for suspected peripheral arterial disease, palpate carotid, abdominal, brachial, radial, ul-
nar, femoral, popliteal, dorsalis pedis, and posterior tibial arteries
● record pulse intensity
⚬ 0 (absent)
⚬ 1 (diminished)
⚬ 2 (normal)
⚬ 3 (bounding)

Neuro

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● for suspected diabetic foot ulcer, consider Semmes-Weinstein monofilament exam for
pressure sensation to rule out neuropathy and test sensation
⚬ 5.07 filament delivers force of 10 g to skin when it buckles
⚬ patient should be supine and eyes closed
⚬ apply monofilament to skin of foot until it buckles and hold position for 1 second
⚬ test several sites on each foot but avoid calluses, scars, or necrotic tissue
⚬ Reference - Mayo Clin Proc 2006 Apr;81(4 Suppl):S3
⚬ see Diabetic Peripheral Neuropathy for details

Diagnostic Evaluation

Diagnostic Approach

CLINICIANS' PRACTICE POINT

Evaluation of lower extremity ulcers in adults requires answering 2 questions: 1) What is the un-
derlying cause of the ulcer? and 2) Is the ulcer infected?

● the underlying cause of most lower extremity ulcers in adults can be suspected clinically
by findings on history and physical
● venous ulcers are characterized by nonhealing ulcer, typically on the lower calf and me-
dial malleolus in setting of chronic edema and signs of venous insufficiency
⚬ venous imaging can confirm diagnosis
⚬ ankle-brachial index or toe-brachial index testing may be needed to assess concomi-
tant peripheral arterial disease
● arterial ulcers are characterized by deep ulceration with necrotic tissue, typically located
at pressure points, toes, and feet in the setting of peripheral arterial disease
⚬ confirm diagnosis with ankle-brachial index or toe-brachial index testing to identify
peripheral arterial disease
⚬ arterial ulcerations may be associated with acute limb ischemia or critical limb ische-
mia which are associated with increased risk of death and limb amputation and may
require immediate treatment (see Management of Acute and Critical Limb Ischemia
for additional information)
● diabetic neuropathic foot ulcers are diagnosed clinically as any break in cutaneous ba-
rrier on the foot in patient with diabetes, without evidence of infection or inflammation
⚬ identify neuropathy with symptoms and monofilament exam for pressure sensation
⚬ assess suspected concomitant peripheral arterial disease with ankle-brachial index or
toe-brachial index testing
⚬ assess suspected concomitant venous insufficiency with venous imaging

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● pressure injury ulcers are usually located over bony prominences in patients with limited
mobility or limited cognition and prolonged pressure to the affected area
● testing to confirm diagnoses
⚬ ankle-brachial index or toe-brachial index testing used to confirm peripheral arterial
disease
⚬ venous imaging used to assess venous insufficiency
⚬ consider biopsy for malignancy, pyoderma gangrenosum, or other suspected vasculi-
tic condition, if diagnosis uncertain
● for evaluation of infection in lower extremity ulcers
⚬ use clinical indicators of infection to guide further evaluation and management 5
⚬ clinical indicators that may be diagnostic of infection of chronic leg ulcer include all of
following 5
– new-onset pain, increasing pain, or altered pain in area of ulcer (pain is unrelated
to any dressing change)
– malodor
– increased size of ulcer; increase of ≥ 20 % in size over < 4 seeks is considered an in-
crease in size
– breakdown of wound
– delayed or nonhealing; delayed healing defined as failure to decrease by at least
20% over 4 weeks
– erythema
– increased temperature of surrounding area
⚬ any exudate of the ulcer should be evaluated for amount, consistency, and type (such
as changing from serous to purulent) 5
⚬ obtain wound swab only if clinical evidence of infection (J Vasc Surg 2014 Aug;60(2
Suppl):3S)
⚬ use validated quantitative swab technique (Levine or curetted specimen) or biopsy to
identify pathogenic microbes (J Vasc Surg 2014 Aug;60(2 Suppl):3S)
⚬ for suspected diabetic foot ulcer/infection, consider probe-to-bone (PTB) test
– probe the wound to determine its depth and any tracking along tendon sheaths or
tissue planes
– positive PTB test has a high predictive value for underlying osteomyelitis in patients
with diabetic foot ulcers or infections, even in patients without acute signs of deep
infection
– see Diabetic Foot Infection for additional information
⚬ see also Venous Ulcer and Diabetic Foot Infection

Ankle-brachial Index and Toe-brachial Index

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● ankle-brachial index (ABI) is the ratio of blood pressure at the ankle to blood pressure in
the upper arm and is used to evaluate peripheral arterial disease (PAD) of lower
extremities
● for evaluation of suspected arterial ulcers
⚬ measure resting ABI (with or without segmental pressures and waveforms) to esta-
blish diagnosis for patients with history or physical examination findings suggestive of
PAD (AHA/ACC Class I, Level B-NR) 6
⚬ measure toe-brachial index (TBI) to diagnose patients with suspected PAD when ABI >
1.4 (AHA/ACC Class I, Level B-NR) 6
⚬ reasonable to evaluate local perfusion with waveforms, transcutaneous oxygen pres-
sure (TcPO2), or skin perfusion pressure in patients with abnormal ABI (≤ 0.9) or with
noncompressible arteries (ABI > 1.4 and TBI ≤ 0.7) in setting of nonhealing wounds or
gangrene in patients with peripheral artery disease (AHA/ACC Class IIa, Level B-NR) 6
⚬ exercise treadmill ABI testing 6
– perform to evaluate for PAD in patients with exertional non–joint-related leg sym-
ptoms and normal or borderline resting ABI (> 0.90 and ≤ 1.40) (AHA/ACC Class I,
Level B-NR)
– useful to establish diagnosis of lower extremity PAD in symptomatic patient when
resting ABIs normal or borderline and to differentiate claudication from pseudo-
claudication in patients with exertional leg symptoms
● diagnosis of PAD confirmed if 6
⚬ ABI ≤ 0.9
⚬ TBI ≤ 0.7
● diagnosis limb ischemia
⚬ reasonable to diagnose critical limb ischemia using TBI with waveforms, TcPO2, or skin
perfusion pressure in patients with normal (1.00–1.40) or borderline (0.91–0.99) ABI in
setting of nonhealing wounds or gangrene (AHA/ACC Class IIa, Level B-NR)
⚬ hemodynamic definition of critical limb ischemia
– in patients with ischemic rest pain
● ankle pressure < 50 mm Hg
● toe pressure < 30 mm Hg
● supine forefoot TcPO2 < 20 mm Hg
● skin perfusion pressure < 30 mm Hg
– in patients with tissue loss
● ankle pressure < 70 mm Hg
● toe pressure < 50 mm Hg
● TcPO2 < 40 mm Hg
● skin perfusion pressure < 40 mm Hg

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– Reference - J Cardiovasc Surg (Torino) 2015 Oct;56(5):775

⚬ additional imaging may be needed
– Doppler and duplex ultrasound
– magnetic resonance angiography (MRA)
– computed tomography angiography (CTA)
– pulse volume recording
– see Peripheral Artery Disease (PAD) of Lower Extremities for additional information
● see Peripheral Artery Disease (PAD) of Lower Extremities for additional information

Imaging

● imaging for suspected venous insufficiency

⚬ duplex ultrasound of deep and superficial veins recommended to complement history
and physical exam in patients with chronic venous disease
⚬ venous plethysmography recommended for evaluation of venous system in patients
with advanced chronic venous disease if duplex scanning does not provide definitive
information on pathophysiology
⚬ see Venous Insufficiency for details
● duplex ultrasound of arterial and venous systems
⚬ initial diagnostic test for patients with suspected chronic venous disease to assess for
venous reflux
⚬ may be used to detect venous reflux, acute or chronic thrombosis, patterns of obs-
tructive flow, postthrombotic changes
⚬ see Venous Insufficiency for additional information
● plethysmography
⚬ measures changes in volume of limb in response to alterations in blood volume
⚬ use venous plethysmography for noninvasive evaluation of venous system in patients
with advanced chronic venous disease if duplex scanning does not provide definitive
information on pathophysiology
⚬ see Venous Insufficiency for additional information
● venography
⚬ magnetic resonance venography, computed tomography venography, ascending and
descending contrast venography, and intravascular ultrasonography selectively used
in patients with chronic venous disease for further assessment
⚬ may be used for planned open or endovascular venous interventions
⚬ see Venous Insufficiency for additional information
● in patients with arterial ulcers and peripheral arterial disease, tests to identify anatomic
location and severity of stenosis include
⚬ Doppler and duplex ultrasound
⚬ magnetic resonance angiography (MRA)

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⚬ computed tomography angiography (CTA)

⚬ pulse volume recording
⚬ see Peripheral Artery Disease (PAD) of Lower Extremities for additional information
● if osteomyelitis suspected, x-ray or magnetic resonance imaging may be used 1

Biopsy

● if diagnosis uncertain or if suspected malignancy, pyoderma gangrenosum, calciphylaxis,

or other suspected vasculitic condition 2
● biopsy may be needed if no improvement after 12 weeks of treatment 2

Management

Management Overview

● for arterial ulcers, urgent or emergent management may be needed for limb ischemia 1
⚬ acute limb ischemia or critical limb ischemia are associated with increased risk of
death and limb amputation and may require immediate treatment
⚬ consult with vascular specialist
⚬ antiplatelet medications or revascularization may be considered
⚬ see Management of Acute and Critical Limb Ischemia for additional information
● initial management of chronic lower extremity ulcers, including vascular ulcers, pressure
ulcers, and diabetic foot ulcers, usually consists of 1
⚬ wound debridement
⚬ infection control
⚬ application of dressings, including compression therapy for venous ulcers
⚬ off-loading of localized pressure
⚬ management of underlying causes
⚬ reduction of risk factors, such as smoking cessation, diet, and hyperglycemia
● wound management may be based on the 4 stages of wound healing using the TIME
acronym
⚬ T - tissue assessment of viability and management of nonviable tissue or foreign ma-
terial, including debridement
– sharp (surgical) debridement (such as with a scalpel, curette, or rongeur) reported
to be the most efficient and commonly used method
– other options for debridement include hydrosurgical or ultrasonic debridement
⚬ I- infection/inflammation management
– clinical infection may need topical antiseptic and/or systemic antibiotics to control
infection

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– treat infection empirically, considering whether patient has systemic as well as local
symptoms 1
– if ulcers do not heal with first course, treat with antibiotics selected based on cul-
ture of wound swab; most infections are polymicrobial, containing gram-negative,
gram-positive, and anaerobic bacteria 1
– also includes management of inappropriate inflammation unrelated to infection,

which may require topical and/or systemic anti-inflammatory drugs

⚬ M - maintain moisture balance with assessment and management of wound exudate
– includes appropriate wound dressings
– for dry wounds (dry black eschar), primary dressing may be povidone iodine paint
with options for secondary dressing of open to air or gauze dressing
– for wet wounds primary dressing options include hydrocolloids, hydrogel, honey-
based dressing, cadexomer iodine, hypertonic saline gel, antiseptic solution-mois-
tened gauze dressing, hypertonic saline-impregnated gauze, calcium alginate, and
hydrofiber
– negative pressure wound therapy may be used as adjunct
– secondary dressings options include gauze, bulky gauze pad, foam, and super ab-
sorbent dressing
⚬ E - edge of wound observation and management with assessment of nonadvancing or
undermined wound edges to encourage reepithelialization
● off-loading pressure
⚬ for venous ulcers, external compression (via bandaging) can help offload the wound
⚬ for diabetic foot ulcers, options include total contact cast, braces, removable cast wal-
kers, irremovable cast walkers (also called instant total contact casts), half shoes, mo-
dified surgical shoes, foot casts, and various felt or foam dressings
⚬ for foot deformities contributing to ulceration, surgical offloading may be needed
● see Treatment of Chronic Wounds for additional information
● consultation and referral may be needed, including
⚬ vascular surgeon if severe necrotizing infection is present or suspected limb
ischemia 1
⚬ wound care specialists or lymphedema therapist for large (> 3 cm) ulcers or ulcers not
improving with standard management 1
⚬ infectious disease specialist for complex infections and infections that are unrespon-
sive to initial treatment 1
● for management of specific ulcers and underlying conditions, see also
⚬ Venous Ulcer
⚬ Peripheral Artery Disease (PAD) of Lower Extremities
⚬ Diabetic Foot Ulcer
⚬ Diabetic Foot Infection

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⚬ Pressure Injury of the Skin and Soft Tissue

Prognosis
● 25%-50% of leg ulcers not fully healed after 6 months treatment 1
● 30% of foot ulcers not fully healed after 6 months treatment 1
● see DynaMed calculator for Venous Leg Ulcer Healing Prediction

Guidelines and Resources

Guidelines

International Guidelines

● International Working Group on the Diabetic Foot (IWGDF) guidelines on

⚬ diagnosis and management of foot infections in persons with diabetes can be found
in Diabetes Metab Res Rev 2016 Jan;32 Suppl 1:45
⚬ prevention of foot ulcers in at-risk patients with diabetes can be found in Diabetes
Metab Res Rev 2016 Jan;32 Suppl 1:16

United States Guidelines

● American Venous Forum/Society for Vascular Surgery/American College of

Phlebology/Society for Vascular Medicine/International Union of Phlebology
(AVF/SVS/ACP/SVM/UIP) clinical practice guideline on compression therapy after invasive
treatment of superficial veins of the lower extremities can be found in J Vasc Surg Ve-
nous Lymphat Disord 2019 Jan;7(1):17
● American Heart Association/American College of Cardiology (AHA/ACC) clinical practice
guideline on management of patients with lower extremity peripheral artery disease can
be found in Circulation 2017 Mar 21;135(12):e726, correction can be found in Circulation
2017 Mar 21;135(12):e791
● Wound Healing Society (WHS) 2015 update guideline on venous ulcers can be found in
Wound Repair Regen 2016 Jan;24(1):136
● Society for Vascular Surgery/American Venous Forum (SVS/AVF) clinical practice guideline
on management of venous leg ulcers can be found in J Vasc Surg 2014 Aug;60(2
Suppl):3S

Asian Guidelines

● Japanese Dermatological Association (JDA) guidelines on

⚬ wounds in general - 1 can be found in J Dermatol 2016 Apr;43(4):357

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⚬ diagnosis and treatment for pressure ulcers - 2 can be found in J Dermatol 2016
May;43(5):469

South American Guidelines

● Brazilian Society of Dermatology [Sociedade Brasileira de Dermatologia] (SBD) consen-

sus on diagnosis and management of chronic leg ulcers can be found in An Bras Derma-
tol 2020 Nov;95 Suppl 1:1

Australian and New Zealand Guidelines

● expert consensus guideline on management of venous leg ulcers in general practice can
be found in Aust Fam Physician 2014 Sep;43(9):594

Review Articles
● review of lower extremity ulcers can be found in Med Clin North Am 2021 Jul;105(4):663
● review of evaluation and management of lower extremity ulcers can be found in N Engl J
Med 2017 Oct 19;377(16):1559, commentary can be found in N Engl J Med 2018 Jan
18;378(3):301
● review of chronic wounds evaluation and management can be found in Am Fam Physi-
cian 2020 Feb 1;101(3):159
● review of diagnosis of infection in chronic leg ulcers can be found in Int Wound J 2019
Jun;16(3):601
● review of diagnosis and treatment of venous ulcers can be found in Am Fam Physician
2019 Sep 1;100(5):298
● review of malignant skin tumors presenting as chronic leg or foot ulcers can be found in J
Clin Med 2021 May 22;10(11):doi:10.3390/jcm10112251
● review of challenges and solutions on pyoderma gangrenosum can be found in Clin Cos-
met Investig Dermatol 2015;8:285

MEDLINE Search
● to search MEDLINE for (Lower Extremity Ulcer in Adults) with targeted search (Clinical
Queries), click therapy , diagnosis , or prognosis

Patient Information
● handouts from Patient UK on
⚬ venous leg ulcers PDF
⚬ diabetes, foot care and foot ulcers PDF
● handout on frequently asked questions of chronic wounds from United Wound Healing

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● handout on venous leg ulcers: are skin grafts effective from Institut für Qualität und Wir-
tschaftlichkeit im Gesundheitswesen (IQWiG) in English or in German

References

General References Used

The references listed below are used in this DynaMed topic primarily to support background in-
formation and for guidance where evidence summaries are not felt to be necessary. Most refe-
rences are incorporated within the text along with the evidence summaries.

1. Singer AJ, Tassiopoulos A, Kirsner RS. Evaluation and Management of Lower-Extremity

Ulcers. N Engl J Med. 2017 Oct 19;377(16):1559-1567, commentary can be found in N
Engl J Med 2018 Jan 18;378(3):301.
2. Bonkemeyer Millan S, Gan R, Townsend PE. Venous Ulcers: Diagnosis and Treatment. Am
Fam Physician. 2019 Sep 1;100(5):298-305.

3. Labropoulos N, Manalo D, Patel NP, Tiongson J, Pryor L, Giannoukas AD. Uncommon leg
ulcers in the lower extremity. J Vasc Surg. 2007 Mar;45(3):568-573.
4. Gameiro A, Pereira N, Cardoso JC, Gonçalo M. Pyoderma gangrenosum: challenges and
solutions. Clin Cosmet Investig Dermatol. 2015;8:285-93.
5. Bui UT, Finlayson K, Edwards H. The diagnosis of infection in chronic leg ulcers: A narra-
tive review on clinical practice. Int Wound J. 2019 Jun;16(3):601-620.

6. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Mana-
gement of Patients With Lower Extremity Peripheral Artery Disease: A Report of the
American College of Cardiology/American Heart Association Task Force on Clinical Prac-
tice Guidelines. Circulation. 2017 Mar 21;135(12):e726-e779, correction can be found in
Circulation 2017 Mar 21;135(12):e791.

Recommendation Grading Systems Used

● American Heart Association/American College of Cardiology (AHA/ACC) 2016 grading

system
⚬ classification of recommendation
– Class I - procedure or treatment should be performed or administered
– Class IIa - reasonable to perform procedure or administer treatment, but additional
studies with focused objectives needed
– Class IIb - procedure or treatment may be considered; additional studies with
broad objectives needed, additional registry data would be useful
– Class III - procedure or treatment should not be performed or administered be-
cause it is not helpful or may be harmful
● Class III ratings may be subclassified as Class III No Benefit or Class III Harm

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⚬ level of evidence
– Level A - high-quality evidence from > 1 randomized controlled trial or meta-analy-
sis of high-quality randomized controlled trials
– Level B-R - moderate-quality evidence from ≥ 1 randomized controlled trial or
meta-analysis of moderate-quality randomized controlled trials
– Level B-NR - moderate-quality evidence from ≥ 1 well-designed nonrandomized
trial, observational studies, or registry studies, or meta-analysis of such studies
– Level C-LD - randomized or nonrandomized studies with methodological limitations
or meta-analyses of such studies
– Level C-EO - consensus of expert opinion based on clinical experience
⚬ Reference - AHA/ACC guideline on management of patients with lower extremity pe-
ripheral artery disease (Circulation 2017 Mar 21;135(12):e726)

Synthesized Recommendation Grading System for DynaMed Content

● The DynaMed Team systematically monitors clinical evidence to continuously provide a

synthesis of the most valid relevant evidence to support clinical decision-making (see 7-
Step Evidence-Based Methodology ).
● Guideline recommendations summarized in the body of a DynaMed topic are provided
with the recommendation grading system used in the original guideline(s), and allow
users to quickly see where guidelines agree and where guidelines differ from each other
and from the current evidence.
● In DynaMed content, we synthesize the current evidence, current guidelines from lea-
ding authorities, and clinical expertise to provide recommendations to support clinical
decision-making in the Overview & Recommendations section.
● We use the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) to classify synthesized recommendations as Strong or Weak.
⚬ Strong recommendations are used when, based on the available evidence, clinicians
(without conflicts of interest) consistently have a high degree of confidence that the
desirable consequences (health benefits, decreased costs and burdens) outweigh the
undesirable consequences (harms, costs, burdens).
⚬ Weak recommendations are used when, based on the available evidence, clinicians
believe that desirable and undesirable consequences are finely balanced, or apprecia-
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harms). Weak recommendations are used when clinicians disagree in judgments of
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mendations are also used when the range of patient values and preferences suggests
that informed patients are likely to make different choices.
● DynaMed synthesized recommendations (in the Overview & Recommendations section)
are determined with a systematic methodology:

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⚬ Recommendations are initially drafted by clinical editors (including ≥ 1 with methodo-

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⚬ Recommendations are phrased to match the strength of recommendation. Strong re-
commendations use "should do" phrasing, or phrasing implying an expectation to
perform the recommended action for most patients. Weak recommendations use
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⚬ Recommendations are explicitly labeled as Strong recommendations or Weak re-
commendations when a qualified group has explicitly deliberated on making such a
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that together have sufficient clinical expertise for the subject(s) pertinent to the re-
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⚬ Recommendations are verified by ≥ 1 editor with methodological expertise, not invol-
ved in recommendation drafting or development, with explicit confirmation that
Strong recommendations are adequately supported.

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⚬ Recommendations are published only after consensus is established with agreement

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⚬ If recommendations are questioned during peer review or post publication by a quali-
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● DynaMed topics are created and maintained by the DynaMed Editorial Team and
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● DynaMed topics are written and edited through the collaborative efforts of the above in-
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● Editorial Team role definitions

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Recommendations Editors provide explicit review of Overview and

Recommendations sections to ensure that all recommendations are sound,
supported, and evidence-based. This process is described in "Synthesized
Recommendation Grading."

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