1 Venous ulcers usually develop above the medial malleoli, in the area drained by incompetent perforating veins. These ulcers are well-demarcated with irregular shaggy borders and surrounding dermatitis, pigmentation and, sometimes, cellulitis. These ulcers are painful, punched out, deep and often filled with tissue slough at the base. Associated chronic ischemic changes, such as loss of hairs, and pale and atrophic skin are usually present in the affected limb. Peripheral pulses are either diminished or absent.
Neuropathic ulcers are common in patients who have diabetes with severe neuropathy.
Common sites are pressure-bearing areas such as the heels, the heads of metatarsals and the great toes. The ulcers are well-demarcated and usually surrounded by thick callus. The extremities are warm, numb and dry, with normal peripheral pulses. Factitious ulcers are an unlikely diagnosis in this patient because there was no history to suggest this unusual and rare behavior. Send photograph and discussion to Marc S. Berger, M.D., C.M., P.O. Box 6825, Wyomissing, PA 19610-0825.