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Knee arthritis, varicose eczema, lower right leg ulcer. Is it Marjolin's ulcer? Is there a risk of limb amputation?

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Practicing since : 2006
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Knee arthritis, varicose eczema lower right leg ulcer 2004-2006 (healed), returned circa 2008 as dime sized, shrinking/enlarging.
Under Dermatology Specialist Centre Tissue Viability Nurse home visits from at least mid 2010 onwards.
Meds 40mg Sotalol 2-daily (occasional AFIB, found with Halter Monitor), Kapake 4-daily 500/30, XXXXXXX Aspirin 1-daily.

Mar 2011 - 14x12.7cm, 20% slough, 80% granulation.
XXXXXXX 2011 - peripheral vestibulitis, lasted 3wks (regular tests for central negative). 115/80 BP. Keeping leg up assisted eczema healing & shrinking to 12.7x12.7cm perhaps as small as 9x7cm. 0% slough, 100% granulation, no odour.
I had the same vestibulitis, nothing like as severe, we believe from a house vent which was not ducted and found to have several dead birds in it. Obviously now completely cleaned up and ducted.

Oct 2011 - Brief hospital visit re chronic IBS bloat, wind, mild diahorrea. No cardiovascular problems. Negative on tests for bowel cancer & repeated consultant physical examination. Negative on X-rays. Discharged with Mebeverine 135mg (3 daily) & Omeprazole (1 daily). Leg ulcer miss-handled by nursing assistant. Peptac AC liquid 15ml (4 daily). Semiticone (Rennie Deflatine) & Peppermint oil capsules worked to relieve IBS symptoms.

Dec 2011 - Tissue Viability Nurse (TVN) requested by District Nurses as ulcer suddenly increased to 14x14cm, malodour +++, 100% slough.
XXXXXXX 2012 - Identical IBS symptoms in relative. Fridge freezer found to be defective, replaced. All IBS symptoms eliminated except atypical trivial wind occasionally.
XXXXXXX 27th 2012 - TVN arrives, requests urgent derma referral. Raised sections in wound, small nodules, strong odour, 100% slough, enlarged 14x14cm extending down to ankle & around side. Slight increase in pain. Swabs always test negative.

Feb 27th 2012 - no change, ?PHBB? german dressing did not help, wound malodour +++.

Mar 21st 2012 - Derma seen. Advise could be infection, could be Basal or Squamous CC, definately not melanoma, not life threatening. Neoplastic changes suspected. KMNO4 anti-septic wash 3x a week, dressed 3x a week. Not quite wet enough for Acquacel AG (etc), but does excudate (???? XXXXXXX S is good for high exudation I believe). "Lots of slough, but it is also trying to granulate as well in places".

Apr 4 2012 - PUNCH biopsy done on TWO sites of wound, LHS & RHS. Awaiting results.

Two photos.
The top 1cm red edge is perhaps original eczema ulcer, the rest is clearly not. There is a cleft on the LHS. The bottom appears lumpy and perhaps progressing under skin by ankle.

There is a "semi-circular prawn" of perhaps a once dome LHS partly detaching with clear yellow (necrosis?) attachment. The broken partly-falling-off prawn appears chicken-flesh like.

There is a very clear differentiated object on the side photo (taken 04-April). This has enlarged since 21-Mar. I will photo again just re "time lapse" at the next dressing (06-April).

Indeed, it could be BCC SCC or could it be a subset of SCC - Kerataocarcinoma (KA). Are these round mounds appearing, self-destructing through lack of nutrition, which results in the heal/no-heal 100% slough, strong odour from their necrosis? (an organic smell, but not affecting the patient).
Or has it already gone Aggressive & Invasive SCC?

Obviously "wait for the biopsy" then most likely radiotherapy.

Q - Is this Marjolin's ulcer with risk of lower limb amputation? That is always a vector with an ulcer.

Q - Has this been found early or late? Not a criticism of them, the TVN was there within 4wks of the DN and myself noticing a clear odour.

Patient IBS has gone almost entirely, just slight wind if sat at the wrong angle (ie, what one would expect).

The patient used to use a zimmer, can even now STILL walk holding-chair-to-holding-chair but complains of "something rubbing on the ankle making it painful".
So I will design alterations for wheelchair as long term future, yet still usable for zimmer or even normal ambulation. I am an ergonomist so such adaptations tailored to her are fine (my mother).

The "front on" photo is after KMNO4.
The "side view" photo is also after KMNO4 and the Biopsy, that is a wet dressing on the photo.

Posted Mon, 21 May 2012 in Skin Hair and Nails
Answered by Dr. Gaurang Krishna 15 hours later

Thanks for writing in and a crisp description and excellent photographs.

To me it looks like a chronic ulcer as a result of medium vessel vasculitis.

The edges are raised but fairly regular and well defined, so chances of invasive SCC are less. BCC is very unlikely.

ANother possibility is of Pyoderma Gangrenosum which is sometimes associated with bowel diseases and arthiritis. The morphology too is quite suggestive of it.

The second pic that shows a nodule is keratoacanthoma which is a benign tumour and can be taken care of.

Getting a biopsy done was the best move.

To answer your questions

1. Marjolin's Ulcer- May be but chances are less. AMputation very very unlikely.
2. I think the nurses have done fine. Ofcourse, had a dermatologist looked earlier, we would have the diagnosis , say a month earlier.

I hope I have answered your query

If you have any further questions, Please do not hesitate to ask me.


Above answer was peer-reviewed by
Follow-up: Knee arthritis, varicose eczema, lower right leg ulcer. Is it Marjolin's ulcer? Is there a risk of limb amputation? 28 hours later
Thank you for your reply.

The "prawn" or half a circle that was pink & cord-like (string-like) on the upper left of the front has turned into a yellow splodge, the odour peaked (it comes & goes in waves).

Q - Could it have multiple KA which are undergoing growth, necrosis, scar?

Q - What is the likely treatment - cream, tablets, radio (multiple fractions)?

Q - What is the prognosis?

Biopsy should be here in a few days, so just a matter of education before.

Answered by Dr. Gaurang Krishna 25 hours later
Multiple KAs are possible but unlikely.

The treatment is usually surical excision.

Prognosis shall be determined once the biopsy report comes.

Pyoderma gangrenosum responds well to treatment.
If there is any scc prognosis depends upon the histological grade

Above answer was peer-reviewed by
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