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Leg ulcer – Information for GPs

Referral criteria / commissioning position

Referral if appropriate:

Refer to vascular surgeon:

  • if ABPI<0.8 (urgent if ABPI<0.5) for assessment of arterial disease
  • if patient may benefit from venous surgery
  • Refer to dermatology:
  • if ulcer failing to progress at 3 months and not healed at 12 months
  • if suspected vasculitic ulcer
  • under 2 week rule if suspected malignant ulcer
  • if diagnosis uncertain

Refer to general surgery:

  • if patient may benefit from skin grafting
  • Refer urgently to Diabetic clinic/podiatry any foot ulcer in a patient with diabetes

Red flag symptoms

  • Exclude malignancy if ulcer not healing after 12 weeks.
  • Bleeding, overgrowth at edge of ulcer and unusual sites are suggestive of malignancy
  • Consider pyoderma gangrenosum or vasculitic ulcer if purple raised edge, painful, unusual site and associated underlying conditions

Investigations prior to referral

  • ABPI measurement to exclude arterial disease and ensure safe to use compression
  • Skin swab only if infection suspected

Information to include in referral letter

  • How long ulcer has been there
  • What treatments have been tried and for how long
  • The appearance of the ulcer edge e.g. shallow, punched out
  • The base of the ulcer e.g. granulating sloughy
  • The site of the ulcer e.g. medial, lateral, anterior, posterior
  • A photograph is desirable
  • ABPI measurements
  • Relevant past medical/surgical history
  • Current regular medication
  • BMI
  • Smoking status
  • Alcohol consumption

Patient information

References

Very good information and pictures by Primary Care Dermatology Society http://www.pcds.org.uk/clinical-guidance/leg-ulcers

Lots of information describing the different types and causes of ulcers and management. http://www.dermnetnz.org/site-age-specific/leg-ulcers.html

Good practical management of leg ulcers and when to refer on patient.co.uk website http://www.patient.co.uk/doctor/leg-ulcers#ref-2

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