Chronic wounds can be caused by a multitude of different diseases. Primary causes include pressure, chronic venous insufficiency, lower-extremity arterial disease, and diabetic neuropathy. Differential assessment of the skin condition or wound, before implementation of management strategies, is essential for understanding its cause and development.
Although most leg ulcers are venous ulcers (see "Venous UlcerChecklist" in the August 2010 issue), the clinician should suspect other causes when the wound looks atypical (presence of necrotic tissue, exposed tendon, livedo reticularis on surrounding skin, or a deep, "punched-out" ulcer), has been present for longer than 6 months, or has not responded to good care. And remember, do not hesitate to take a biopsy when in doubt.
The following table provides with you a checklist for the "differential diagnosis of lower-extremity ulcers." In addition, review screening laboratory tests for these diagnoses (see next issue for a comprehensive checklist). At the end of the day, no matter how clinically competent we are, integrating checklists into our practice will improve our clinical and operational outcomes. If you have a checklist to share with our readership, please e-mail email@example.com. Good luck!
Source: Hess CT. Clinical Guide to Skin and Wound Care. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.