Neuropathic Ulcers

Synonyms

Neurotrophic ulcer, Acroosteopathia ulceromutilans, malum perforans.

Epidemiology

Prevalence up to 50 (6-51) % of patients with diabetes during their lifetime. There are no published statistics on the epidemiology of malum perforans in late-stage syphilis, leprosy or nerve injuries. The alcohol-induced malum perforans occurs exclusively in males with a distinct genetic disposition.

Definition

Ulceration in areas of physical/mechanical pressure on the basis of polyetiologic sensory polyneuropathy. Disturbance of the “trophic of the tissue”, not of the venous or arterial circulation.

Aetiology & Pathogenesis

Sensory polyneuropathy with preference of thin nerve fibers on the basis of a genetic predisposition. Dissociated sensation deficit with loss of thermo-, pressure- and pain-sensation. Potential causes are:

Metabolic disorders: diabetes; rarely amyloidosis
Alcohol (Bureau-Barrière-syndrome)
Infectious:
Syphilis (III/IV)
Leprousy
Nerve trauma (Ischias)
Hereditary (Thevenard-syndrome)

Signs & Symptoms

Loss of thermo- and pressure sensitivity and of pain. Formation of a localized hyperkeratosis with a hemorrhagic bulla and finally ulceration. Fractures of the underlying bones (foot or toes) (Acroosteopathia ulceromutilans). Hyperthermy of the involved limb with an- (diabetes) or hyperhidrosis (alcoholic polyneuropathy).

Localisation

Areas of mechanical pressure; preferentially heel and ball of the foot and toes.

Classification

According to aetiology.

Laboratory & other workups

Search for underlying disease. Imaging methods (x-ray; MRI). Determination of the (severely reduced) nerve conduction velocity. Neurologic status. Orthopedic counseling.

Dermatopathology

Not indicated.

Course

Chronic; depending on the underlying disorder.

Complications

Superinfection; (painless) fractures; mutilation.

Diagnosis

Clinical picture of painless ulcer in conjunction with an underlying disorder (see aetiology).

Differential diagnosis

Venous or arterial ulcers.

Prevention & Therapy

Prevention: avoidance and treatment of the aetiopahogenetic background.

Since the polyneuropathy is irreversible (vitamin B-complex may be supportive in some instances), the only effective treatment is avoidance of pressure by appropriate orthopedic shoes. Plastic reconstructive surgery must be an exception, since the benefit is only temporary.

Special

Cooperation with internal medicine and orthopedics.

5.2.3 Neuropathic Ulcers