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The management of malignant lower limb ulcers: clinical considerations

13 August 2020
Volume 29 · Issue 15


Lower limb malignant ulcers are an uncommon finding, making diagnosis complex and their management costly. Yet, despite this, the increase in skin cancers over the past 30 years means that clinicians require an awareness and understanding of their existence, particularly in the primary care setting. Familiarity with common aetiologies and presentations is vital for prompt recognition, diagnosis and referral of wounds suspicious for malignancy. Lower limb malignant wounds often develop insidiously, with a wide variation in clinical presentation that overlaps between entities. Therefore, a fundamental algorithm for approaching lower limb ulcers that raise suspicion of malignancy should be possessed by all clinicians. This article reviews the clinical features of malignant wounds that should alert clinicians to the need for further evaluation, such as atypical location and appearance. The authors also highlight the various diagnostic and therapeutic modalities available and review current clinical guidelines for the referral and follow-up of suspicious lesions.

As clinicians, awareness of malignant wounds and their management is important to ensure that patients are treated in a timely fashion. Malignant ulcers are fortunately uncommon, accounting for 2-4% of lower limb wounds, but they often present in insidious ways, with features overlapping with other pathologies (eg venous changes) that can potentially delay diagnosis (Lautenschlager and Eichmann, 1999). That said, over the past 30 years skin cancer incidence rates have risen dramatically in England, with a projected cost to the NHS in 2020 likely to be in the region of £180 million (Vallejo-Torres et al, 2014).

A high index of suspicion for wounds that ‘just don't seem right’ or fail to heal in a typical fashion with standard treatments should raise suspicion for malignancy. A correct, early diagnosis is essential to avoid inappropriate investigations or treatment.

When faced with a clinical conundrum, it is always useful to take a back-to-basics approach. Revisiting the history of a chronic wound can identify important information that may have been overlooked in differentiating its aetiology. A thorough history may, for example, elicit a history of deep venous thrombosis (eg following surgery or pregnancy) or venous symptoms (aching, throbbing and swelling of the leg(s), that is particularly worse at the end of the day or exacerbated by prolonged periods of standing/dependency and relieved by elevation). There may be a history of intermittent claudication (muscle discomfort, fatigue, aching or cramping most commonly localised to the calf, but which may also affect the thigh or buttocks, that is reproducible by exercise and relieved by rest within 10 minutes (Norgren et al, 2007)), suggestive of arterial insufficiency as the underlying problem.

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