AKT · Dermatology/Wounds, ulcers & burnslow yield

Arterial (ischaemic) ulcer

Peripheral arterial disease → tissue ischaemia

Overview

A leg/foot ulcer from inadequate arterial supply (peripheral arterial disease). PUNCHED-OUT, painful ulcers at the distal points and pressure areas (toes, heel, lateral malleolus), with a cold, pulseless, hairless limb. Compression is contraindicated — these need revascularisation.

Recognise

Deep, well-defined "punched-out" ulcer with a pale/necrotic base, on the toes, heel or lateral malleolus
PAINFUL — worse on elevation and at night, relieved by hanging the leg down (dependency); intermittent claudication/rest pain history
Cold, pale, hairless, pulseless limb with prolonged capillary refill; ABPI <0.8 (often <0.5 in critical ischaemia)

Red flags

Rest pain, gangrene, or rapidly deteriorating ischaemia = critical limb ischaemia → urgent vascular referral

Differentials & how to tell them apart

Venous ulcershallow, gaiter area, relatively painless, ABPI 0.8–1.3 with venous skin changes — opposite management (compression)

Neuropathic ulcerpainless, over plantar pressure points, with peripheral neuropathy

Mixed arteriovenous ulcerfeatures of both, intermediate ABPI — compression must be modified/avoided

Clinical image

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Arterial (ischaemic) ulcer — clinical imagesDermNet

Investigations

ABPI (<0.8 confirms arterial disease; <0.5 critical), Doppler/duplex, and angiography (CT/MR) to plan revascularisation; assess cardiovascular risk factors.

Management

Urgent vascular referral for revascularisation + cardiovascular risk management (NO compression)

1Confirm arterial disease (ABPI <0.8) and refer to vascular surgery for assessment/revascularisation; aggressive cardiovascular secondary prevention; analgesia and wound care.Gate: Do NOT apply compression to an arterial ulcer — it worsens the ischaemia; the low ABPI that contraindicates compression in venous disease is precisely what defines an arterial ulcer
2Revascularisation (angioplasty/stent or bypass); critical limb ischaemia/gangrene → urgent vascular input; optimise risk factors lifelong.

Revascularisation (angioplasty/bypass) — the definitive treatment for the ischaemia

Cardiovascular risk reduction (statin, antiplatelet, BP, smoking cessation, diabetes control) — secondary prevention

Analgesia + wound care; do NOT compress — compression worsens ischaemia

Key points

Punched-out + painful + pulseless + on the foot = arterial. The single safety point: never compress an arterial ulcer. ABPI is the decisive test that also flags critical ischaemia.

Monitor & prognosis

ABPI, healing, limb viability, cardiovascular risk.

Depends on revascularisation; poor with untreated critical ischaemia.

Source: NICE CKS; NICE CG147 (peripheral arterial disease)