FFinalistSouthampton · 2027
Dermatology
AKT · Dermatology/Wounds, ulcers & burnslow yield

Neuropathic ulcer

Peripheral neuropathy → painless pressure-point breakdown

Overview

A PAINLESS ulcer at a weight-bearing pressure point, caused by the loss of protective sensation (peripheral neuropathy — most often diabetic). Repeated unnoticed trauma over a bony prominence (metatarsal heads, heel) breaks the skin, often with surrounding callus. Part of the diabetic foot, managed by offloading.

Recognise

  • Painless ("the patient does not feel it") ulcer over a plantar pressure point — metatarsal heads, heel, or other bony prominence
  • Surrounding hyperkeratotic callus; warm foot with palpable pulses (if pure neuropathy) but absent sensation (10 g monofilament)
  • Diabetes is the commonest cause; deformity (Charcot foot) redistributes pressure

Red flags

  • Deep ulcer probing to bone (osteomyelitis), spreading infection, or a hot swollen foot (Charcot) → urgent diabetic foot MDT

Differentials & how to tell them apart

Arterial ulcerpainful, punched-out, on the toes with absent pulses — neuropathic ulcer is painless over plantar pressure points with callus
Venous ulcergaiter area with venous skin changes
Osteomyelitis underlying the ulcerprobe-to-bone positive, deep — image and treat

Clinical image

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Neuropathic ulcer — clinical imagesDermNet

Investigations

Assess sensation (10 g monofilament), pulses and ABPI (to detect coexisting arterial disease), depth/probe-to-bone, X-ray/MRI for osteomyelitis, wound swab if infected; check glycaemic control.

Management

Offloading (pressure relief) + diabetic foot MDT referral + glycaemic control

  1. 1Refer to the diabetic foot MDT. The central treatment is OFFLOADING (total-contact cast/specialist footwear) plus callus debridement, wound care and glycaemic control.Gate: A painless ulcer over a plantar pressure point with callus is NEUROPATHIC — the answer is pressure OFFLOADING, not compression (venous) or revascularisation alone (arterial); always also check ABPI for a coexisting arterial component
  2. 2Treat infection/osteomyelitis (probe-to-bone, imaging, antibiotics ± surgery); address any arterial disease; lifelong foot protection, education and surveillance.
OFFLOADING (total-contact cast / specialist footwear) — the key intervention — remove the pressure
Debridement of callus + wound care — diabetic foot specialist
Antibiotics if infected; revascularise if mixed — treat infection/osteomyelitis; address any arterial component
Glycaemic control — optimise diabetes

Key points

Painless + pressure point + callus + neuropathy = neuropathic. Offloading is the high-yield management word. Always exclude osteomyelitis (probe-to-bone) and coexisting arterial disease.

Monitor & prognosis

Healing, sensation, infection/osteomyelitis, glycaemic control.

Heals with offloading + good control; high recurrence and amputation risk if neglected.

Source: NICE NG19 (diabetic foot problems); NICE CKS