Department Editor Tania Phillips, MD, FRCPC Overall Learning Objective: The physician or podiatrist participant will develop a rational approach to the evaluation and treatment of a variety of uncommon wounds and will have an increased awareness of the differential diagnosis of cutaneous wounds and the systemic diseases associated with these wounds. Submissions: To submit a case for consideration in Diagnostic Dilemmas, e-mail or write to: Executive Editor, WOUNDS, 83 General Warren Blvd., Suite 100, Malvern, PA 19355, Completion Time: The estimated time to completion for this activity is 1 hour. Target Audience: This CME/CPME activity is intended for dermatologists, surgeons, podiatrists, internists, and other physicians who treat wounds. Objectives: At the conclusion of this activity, the participant should be able to: 1. Recognize hypertensive ulcers as uncommon causes of leg ulcers 2. Describe and discuss treatment options of hypertensive ulcers 3. Apply the relative points of this case presentation to his or her own patient population. Disclosure: All faculty participating in Continuing Medical Education programs sponsored by HMP Communications, LLC, are expected to disclose to the program audience any real or apparent conflict(s) of interest related to the content of their presentation. Drs. Bello, Falabella, Kirsner, Elgart, and Kerdel disclose no financial conflicts. Accreditation: HMP Communications, LLC, is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. HMP Communications, LLC, is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine. Designation: HMP Communications, LLC, designates this continuing medical education activity for 1 credit hour in Category 1 of the Physician’s Recognition Award of the American Medical Association. Each physician should claim only those hours he/she spent in the educational activity. HMP Communications designates this continuing medical activity for .1 CEUs available to participating podiatrists. Method of Participation: Read the article, take, submit, and pass post-test by May 1, 2003. This activity has been planned and produced in accordance with the ACCME Essential Areas and Policies. Release date: May 1, 2002 Expiration date: May 1, 2003 Hypertensive Ulcer Presentation A 51-year-old man presented with a painful ulcer on his right lateral leg. He had a history of refractory hypertension, atrial fibrillation, hypercholesterolemia, and diabetes mellitus. He had a previous venous ulcer on the right medial malleolus that healed with compression therapy. His medications included warfarin sodium, losartan potassium, enalapril maleate, torsemide, amiodarone, gabapentin, metformin, and glimepiride. Physical Examination On physical examination, his blood pressure was consistently elevated (typically 200/160mmHg) despite antihypertensive therapy. On presentation, he had a 2cm x 2cm ulcer located on the right leg above the lateral malleolus covered with black eschar. Peripheral pulses were palpable bilaterally. Despite debridement and compression, the ulcer progressed to an elongated, irregularly shaped ulcer of 15cm x 9cm, with some areas covered with fibrinous slough or black eschar surrounded by a purple border without undermining (Figure 1A). Pathology Cryoglobulins, cryofibrinogens, antinuclear antibodies, P-ANCA and C-ANCA, RPR, Hepatitis B screen, ASO titer, and rheumatoid factor were negative. Antiphospholipid antibodies were negative. An arterial duplex scan of the right lower extremity reported a patent lower-extremity arterial tree. A venous duplex scan was negative. A biopsy did not show vasculitis or neutrophilic inflammation typically seen in pyoderma gangrenosum, but subendothelial hyalinosis was noted in some arterioles (Figure 1B). Wound cultures for fungus and acid fast bacilli (AFB) were negative. Diagnosis The patient was diagnosed with a hypertensive ulcer, an uncommon cause of leg ulcers. The diagnosis of hypertensive ulcer was based on localization and characteristics of the ulcer, refractory hypertension, and a strongly palpable pulse. Discussion Hypertensive leg ulcers are uncommon, and the diagnosis is often not considered. Martorell described the first four cases of this clinical entity in 1945,1 and some of the literature refers to these ulcers as Martorell’s ulcers. Hines and Faber reported additional cases.2 The condition has been reported in both women1 and men.3–5 Clinically, it commences with a reddish patch, which soon becomes cyanotic, resulting in an ulcer with a grayish bed.6 Typical of a hypertensive ulcer is a superficial ulcer located in the supramalleolar region on the anterolateral aspect of the leg associated with significant arterial hypertension without arterial occlusion and with the presence of a perceptible pulse in all arteries of the lower limbs in the absence of other causes of leg ulcers.6 These ulcers are extremely painful and may be localized on the anterolateral or posterolateral aspect of the leg, at the junction of the lower and median third of the lower leg. They have irregular, ragged edges, surrounded by necrotic or cyanotic borders and poor granulation tissue.7 Hypertensive ulcers are the result of ischemia caused by obliterating lesions of the small arterioles. The histological findings seen in some cases include subendothelial hyalinosis of the arterioles or enlargement and nuclear multiplication of tunica media, both of which lead to stenosis of the lumen.6 If the arteriolar narrowing is severe, the tissue perfusion is reduced to a level that results in local ischemia and ulcer formation.8 The coincidence of diabetes in our patient does not exclude the diagnosis of a hypertensive ulcer given that some cases of hypertensive ulceration have been described in diabetic patients.9,10 However, the hypertensive ulcer should be differentiated from chronic venous ulcers, arteriosclerotic ulcers, diabetic ulcers,9 and pyoderma gangrenosum, as well as ulcers due to vasculitis or vasculopathy. The diagnosis of hypertensive ulcer should be based on existence of arterial hypertension; absence of arterial occlusion (palpable pulses in all arteries of the lower limbs); absence of disturbance of venous circulation; presence of superficial ulcer on the antero-exterior aspect of the leg at the union of the lower and upper third; and symmetry of the lesions, bilateral ulcers, or ulcers on one side and pigmented patch on the opposite side.6 Both legs may be affected simultaneously or sequentially. However, symmetrical sites are not always found, and unilateral ulcers have been described.9,11 Aggressive debridement techniques are found to potentiate the necrosis, resulting in “growth” of the lesion due to the inability of local tissues to initiate wound healing, establish bacteriologic defense mechanisms, and respond adequately to the traumatic intervention of the mechanical debridement.7 The treatment includes control of hypertension, enhanced local tissue perfusion, and skin grafting. Treatment of the hypertension is indicated to detain or retard further progress of the underlying disease process.12 Small ulcers, less than 3cm to 4cm in diameter, will often close by conservative management, including avoidance of frequent dressing changes and the use of non-adherent dressings, but ulcers larger than 4cm should be closed surgically by the application of a split-thickness skin graft, which should cover the entire skin surface.7 The wounds should be covered with an occlusive dressing and the leg should be bandaged from the metatarsal area up to below the knee.9 Lumbar sympathectomy has been described as therapy for this condition; however, it is doubtful whether it contributes to healing of the ulcers.9 Patient Management Despite local wound care and compression therapy, this patient’s ulcer increased in size. The ulcer progressed and became elongated and irregularly shaped measuring 16.5cm x 12cm (Figure 1C). Conservative ulcer debridement for removal of black eschar generated enlargement of the ulcer and the rapid appearance of the dry eschar, despite the use of hydrogel dressings. Intralesional triamcinolone at a dose of 20mg/mL was initially injected to the periwound area without success. A living skin equivalent was applied on three different occasions, eight weeks and five weeks apart, with improvement of the ulcer base. A wound culture showed Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. The patient was treated with intravenous vancomycin. Outpatient therapy of the patient’s blood pressure failed to regulate his hypertension. The patient was admitted to the hospital, and his blood pressure was controlled with nitroglycerin ointment and furosemide. A split-thickness skin graft was performed with healing of 60 percent of the ulcer. Subsequently, smaller split-thickness pinch grafts were performed as outpatient treatment until the ulcer healed after five months (Figure 1D). Conclusion The recognition of this unusual entity will allow for early implementation of adequate treatment and better prognosis for those patients who present with hypertensive ulcers. How to obtain educational credits by reading this article Successful completion entails scoring at least 70 percent on the questions, completing the entire evaluation form (below) and submitting it online or printing it off and mailing or faxing it to the correct address listed below. Certificates will be mailed to those who successfully complete the learning assessment by May 1, 2003. Fax the completed form to: (610) 560-0501 or mail the completed form to: Trish Levy, CME Director HMP Communications, LLC 83 General Warren Blvd. Suite 100 Malvern, PA 19355 Questions 1. Hypertensive ulcer is: A) A frequent cause of leg ulcer B) An unusual and often unconsidered diagnosis C) Always associated with diabetes mellitus D) Present without high blood pressure E) None of the above 2. The diagnosis of hypertensive ulcer is based on: A) Localization on the lateral aspect of the leg B) The presence of palpable pulses and lack of arterial occlusion C) Ulcer surrounded by a cyanotic border D) Severe pain out of proportion to the ulcer characteristics E) All of the above 3. The histological findings in a hypertensive ulcer include: A) Lymphocytic infiltrate B) Nuclear enlargement of the tunica media C) Subendothelial hyalinosis D) B and C E) Vessel dilatation 4. Concomitant diabetes mellitus: A) Excludes the diagnosis of hypertensive ulcer B) Confirms the diagnosis of hypertensive ulcer D) Can coexist with hypertension in a case of hypertensive ulcer D) All of the above E) None of the above 5. The treatment of hypertensive ulcer includes: A) Control of the hypertension B) Skin grafts C) Aggressive debridement D) A and B E) Vacuum-assisted closure Answer Form and Evaluation Hypertensive Ulcers Please print clearly: Name Degree Position/Title Organization/Institute Department Mailing Address for Certificate (H or W): City State Zip Code Email Address Social Security Number Phone (area code) Fax (area code) Answer Form (circle one) 1. A B C D E 2. A B C D E 3. A B C D E 4. A B C D E 5. A B C D E Evaluation (circle one) Excellent (4) Good (3) Satisfactory (2) Poor (1) Accuracy and timeliness of content: 4 3 2 1 Relevance to your daily practice: 4 3 2 1 Impact on your professional effectiveness: 4 3 2 1 Relevance of the content to the learning objectives: 4 3 2 1 Effectiveness of the teaching/learning methods: 4 3 2 1 This activity avoided commercial bias or influence YES NO Now that you have read this article, can you: 1. Recognize hypertensive ulcers as uncommon causes of leg ulcers YES NO 2. Describe and discuss treatment options of hypertensive ulcers YES NO 3. Apply the relative points of this case presentation to his or her own patient population. YES NO What questions do you still have? How will you use what you have learned from this activity? All tests must be received by 5/1/03.