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Differential diagnosis

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Is the ulcer of purely vascular origin, arterial or venous, is there an element of neuropathy, or is ulceration occurring as part of a generalized disease process?

  • Arterial ulcer:
    • typically on the dorsum of the foot with a punched-out appearance, with ischaemia and necrosis. This is typical in a person with atherosclerosis; pale or blue, mottled, shiny, cold skin; prolonged capillary refill; nail dystrophy; reduced hair growth; and calf muscle wasting of the limb
  • Combined arterial and venous insufficiency:
    • seen in 10-20% of leg ulcers (1)

Systemic diseases in which there are often leg ulcers include:

  • diabetes mellitus: ulcer is typically on the foot over a bony prominence. This may have neuropathic, arterial, or venous components (1)
  • rheumatoid arthritis (vasculitic) - the ulcer is typically deep, well demarcated and punched out on the dorsum of foot or calf. Persons with rheumatoid arthritis might also have venous disease due to reduced mobility, neuropathy, and possibly impaired healing due to systemic corticosteroids
  • syphilis: ulcer with undermining edge (1)
  • chronic ischaemia due to atherosclerosis
  • spinal cord lesions
  • systemic vasculitis associated with polyarteritis nodosa, SLE, scleroderma or Wegener's granulomatosis:
    • multiple leg ulcers that are deep and necrotic. There is usually an atypical distribution with vasculitic lesions like nail-fold infarcts and splinter haemorrhages elsewhere (1)
  • malignancy - especially if the ulcer is long standing and slightly atypical
  • sickle cell disease and other haemoglobinopathies; in patients of Mediterranean origin
  • Other possible causes for leg ulcers include traumatic ulcer, sarcoidosis, tropical ulcer, or pyoderma gangrenosum


1. Pannier F. Differential diagnosis of leg ulcers. Phlebology 2013 Mar:28 Suppl 1:55-60.

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