Lower Limb Ulceration

Lower limb ulcers are uncommon in patients with systemic sclerosis (SSc), but when they do occur can be very difficult to heal due to a combination of poor blood supply and (in some patients) the tightness of the surrounding skin. SSc-related microangiopathy (leading to ischaemia) is likely to be the major contributory factor in many patients, but arterial and venous insufficiency should always be considered, as should the many other causes of cutaneous ulceration, for example, infection, skin malignancy, and pyoderma gangrenosum. In this chapter, four cases of SSc-related lower limb ulceration are presented to illustrate: ischaemic toe ulcers, ulcers overlying areas of calcinosis, ‘mechanical’ ulcers over the malleoli in diffuse cutaneous SSc, and small superficial ulcers/erosions in early diffuse cutaneous SSc and rapidly progressive scleroderma. The approach to investigation and management are discussed, and some practical tips for the clinician are provided. Management includes treatment of any concomitant large vessel disease, expert wound care by a skilled nursing team, treatment of any secondary infection, optimising blood flow with vasodilator therapies, analgesia, antiseptics, and (in some patients) compression bandaging.