Case 1

Women 35 years old, complained an ulcer on the lower leg since 2 years ago.
She had history of recurrent eczema on the lower leg. From sin e!amination
there is an ulcer with irregular edges, with the "ase of the ulcer contain with
e!udates. #he sin surrounding the ulcer is hyperpigmented. $atient come to
you, asing for e!planation and treatment.
Case 2
%an &' years old, complained an ulcer on the lower leg since 1 years ago. (e
had history of dia"etes militus from 3 years ago. From sin e!amination there
is an ulcer with undermined edges and the sin surrounding the ulcer is
contain with necrotic are. $atient come to you, asing for e!planation and
treatment.
Draw and explain the etiology, patophysiology, diagnosis, dif.
diagnosis, and treatment of all cases above
Case 1
)tiology
*ncreased pressure in the +enous system of the lower leg. *t is caused "y
insu,ciency of the +al+es in the deep +enous system and lower perforating
+eins of the lower leg.
$atophysiology
-ysfunction of +al+es in the super.cial and/ or communicating and or
deep system
-eep +enous out0ow o"struction 1ie, throm"us formation2
%uscle dysfunction and calf muscle pump failure
*t result from increased pressure in the +enous system of the lower leg. #he
most common cause is insu,ciency of the +al+es in the deep +enous system
and lower perforating +eins of the lower leg. With each contraction of the
calf, "lood should "e pumped the the heart 1muscle pump2. *ntact +al+es in
the lower leg are re3uired to pre+ent this 4pumped5 "lood from re0u!ing out
through the perforators into the super.cial system.
-iagnosis
6enous ulcer
-i7erential diagnosis
8rterial ulcer, neuropathic ulcer
#reatment
#reatment is primarily to impro+e +enous return and reduce edema. #his is
done "y9
Compression therapy with the use of pressure wraps, such as :nna
"oots co+ered with co"an or elastic wraps.
)le+ation of the leg a"o+e the heart as much of the time as possi"le 1a
minimum of 2 hours twice a day2.
)lastic support of the legs must "e continued after the ulcer heals.
*f there is a central cause of 0uid retention 1cirrhosis, heart failure,
renal failure2 diuretics may "e "ene.cial, "ut otherwise they are "est
a+oided.
$ento!yphylline ;'' to <'' mg three times a day in addition to
compression for healing refractory +enous ulceration.
=cclusi+e and semipermea"le "iosynthetic wound dressing can "e +ery
e7ecti+e when com"ined with compression.
-ressings containing dilute acetic acid or sil+er may help reduce
"acterial o+ergrowth in the wound, as will the application of topical
metronidazole gel '.'>5?.
@ecaplermin 1Aegrane!2 promotes wound healing, "ut e!pensi+e
*nBection of granulocyteCmacrophage colonyCstimulating factor 1D%C
CSF2 into the ulcer "ase may stimulate refractory ulcers to heal.
Case 2
)tiology
-ia"etes %elitus
$atophysiology
#he patient su7er from dia"etes
-iagnosis
Eeuropathic ulcer
-i7erential diagnosis
6enous ulcer, arterial ulcer, and other causes of ulcers 1hematopoietic ulcers,
collagen +ascular disease, malignancy, infectious2
#reatment
=Foading the ulcer is the primary principal of management. Eecrotic tissue
should "e de"rided "ac to "leeding +ia"le tissue. 8s the foot is typically
insensate, this can "e done in the o,ce without the need for anesthetic.
8ssociated osteomyelitis is "est treated "y remo+al of the infected "one.
6arious shoes and padded "oots can "e used to oFoad di7erent areas of the
foot. Clinical infection should "e treated, "ut simple colonization typically
does not re3uire treatment. 8fter the ulcer heals, a shoe of appropriate depth
and width will help to pre+ent recurrence.
6ignette
8 "oy aged 5 years old "rought "y his mother to the dermato+enereology
clinic at Sanglah (ospital with symptoms of itching in "oth his legs and
hands. Clinically there are "lacish papule and esoriasi. #his complaint has
su7ered since the 3CyearCold patient, "esides that, the patient also su7ered
from asthma, swollen with red "umps at his sin.
Gearning #as
1. What ind of anamnesis do we needs to "e ased in this patientH
#he anamnesis include the use of sacred se+en and fundamental fours.
#he 3uestion we should as include the factors to occurrence of prurigo
such as food and drug allergy, emotional stress and di7erent
psychogenic factors, allergic contactants, insect "ites ectoparasites,
etc. 8lso we should as a"out the intense pruritus to esta"lish the
diagnosis.
2. (ow is the e0oresensi of this patientH
(yperpigmented papule, esoriasi
3. What are the di7erential diagnosis of this patientH
Eeurodermatitis
-ermatitis herpetiformis
Chronic atopic dermatitis
(erpes gestationis
;. What is the diagnosis of this patient
$rurigo mitis
5. (ow are the management of this patientH
Gocal applications are of little +alue. 8+oid irritating su"stances,
insect "ites, a+oid o+er heating or e!posing the sin to cold.
*ntralesional inBection of the nodules with a steroid such as
triamcinolone is often helpful.
8ntihistamines9 me"idrolyn napadisilic, loratadin
#ran3uilizers9 may "e of great help especially in emotionally
distur"ed indi+iduals. (igher doses can "e gi+en at night, where
itching is more in some patients due to sin heating especially in
wintertime.
corticosteroids topical and systemic9 deso!imetasone
cream/ointment, methylprednisolon , prednison can "e gi+en e+ery
2C; wees.