Dos Santos Modesto Vitorino1,2*, Modesto Campos Julia2
1 Armed Forces Hospital. Brasília – DF, Brazil.
2 Catholic University of Brasília, Medical Course.
Brasília – DF, Brazil.
Lower limb, pressure and neoplastic ulcers can be complications of
circulatory, neurological and metabolic disorders of aging. Health care
must assess the quality and not only the quantity of life of these patients.
Therefore, non-specialist professionals need to obtain adequate prior
training to deal with these injuries. The aim of these comments is to
emphasize the training of primary health care workers on the diagnosis
and management of leg ulcers in low- and medium-income countries.
Herein are included a very recent Ecuadorian and two previous Brazilian
manuscripts. The main factors related to etiology, management and
prognosis are commented on.
Úlceras en miembros inferiores, por presión y neoplásicas pueden
ser complicaciones de alteraciones circulatorias, neurológicas y
metabólicas del envejecimiento. La asistencia sanitaria debe valorar
la calidad y no solo la cantidad de vida de estos pacientes. Por lo
tanto, los profesionales no especialistas deben obtener una formación
previa adecuada para hacer frente a estas lesiones. El objetivo de
estos comentarios es enfatizar la formación de los trabajadores de
la atención primaria de salud en el diagnóstico y tratamiento de las
úlceras de las piernas en los países de ingresos bajos y medios. Aquí
se incluyen un manuscrito ecuatoriano muy reciente y dos brasileños
anteriores. Se comentan los principales factores relacionados con la
etiología, el manejo y el pronóstico.
Dear Editor:
Ulcers affecting the lower limbs constitute a frequent cause of outpatient
attention in primary care settings mainly in individuals with comorbidities,
and these patients are more often evaluated and managed by non-
specialized professionals. (1,2) Malignancies may develop at the site
of burn scars and non-healing chronic ulcers, and late diagnosis or
misdiagnosis can propitiate the occurrence of severe outcomes. (2)
Rosero Arboleda and Loor Zambrano commented on the role of primary
care for lower limb ulcers, involving possible diagnostic failures and
lack of specialized care (1). They reported an 86 year-old woman with
hypertension, diabetes type 2, and a healed wound of the right leg,
which after local trauma evolved as an irregular, painful ulcer without
signs of infection. The lesion was managed by a family doctor in a
primary care ofce, and also a vascular surgeon through telemedicine,
with the healing in 9 months. The authors focused on comorbidities,
longstanding course, and the 30% of recidivism in this condition, which
includes venous, arterial, neuropathic, and malignant causes; besides
the importance of early signs of infection and unidentied foreign
body (1). They accented the need for individualized management of
these ulcers by debridement, irrigation, dressings, bandages, alginate,
hydrocolloid, corticosteroids, antimicrobials, analgesics, avonoids,
troxerutin, glycosaminoglycans, and pentoxifylline, and control of
Revista Médica Vozandes
Volumen 32, Número 2, 2021
* Corresponding author:
Vitorino Modesto dos Santos
E-mail: vitorinomodesto@gmail.com.
Key words: Diagnosis; Leg ulcer; Quality of life; Treatment.
Palabras clave: Diagnóstico; Úlcera de la pierna; Calidad de vida; Tratamiento.
Forma de citar este artículo: Santos
VM, Modesto JC. LEG ULCER: A
Vozandes. 2021; 32 (2): 12 - 13
Vitorino Modesto dos Santos
Julia Campos Modesto
Conflict of interest: The authors declare no
conict of interest.
Financial disclosure: The authors have no nan-
cial relationships relevant to this article to disclose.
Este artículo está bajo una
licencia de Creative Com-
mons de tipo Reconocimien-
to – No comercial – Sin obras
derivadas 4.0 International.
DOI: 10.48018/rmv.v32.i2.1
Received: 06 – Jun – 2021
Accepted: 22 – Ago – 2021
Publish: 20 – Dic – 2021
Revista Médica Vozandes
Volumen 32, Número 2, 2021
management in two or four weeks (1). They concluded that
more specic training of primary care workers is necessary
to promptly and adequately control leg ulcers.
In this setting, two previous Brazilian case studies might be
of some interest. (2,3) A Marjolin’s ulcer due to a squamous
cell carcinoma was described in a 73-year-old woman
with a traumatic leg ulcer, and the malignancy evolved
unsuspected on the lesion border in association with local
venous insufciency and lymph edema. (2) She presented
hypertension, diabetes type 2, congestive heart failure, and a
non-healing infected vegetating lesion on her left leg. Thirty-
ve years before admission, she had an ulcer developed
due to trauma over a site of chronic venous insufciency.
Worthy of note, the average time for malignant changes in
chronic Marjolin’s ulcer is 35 years, differing of the acute type
that develops in less than one year. (2) Differential diagnoses
included pseudoepitheliomatous hyperplasia, basal cell
carcinoma, melanoma, sarcoma, hanseniasis, leishmaniasis,
mycosis, syphilis, tuberculosis, and mycobacteriosis (2)
The authors highlighted the very aggressive behavior of
this malignant cutaneous tumor, the role of adequate
management of primary ulcers, the ominous late diagnosis,
and the enhancing of suspicion index of primary care workers
about this challenging entity. (2) Before the surgical procedure
and postoperatively, the patient was treated by the
dermatology team, and the leg lesions were solved in
approximately 1 month.
Another report was a 65-year-old woman with chronic
seropositive rheumatoid arthritis (RA) and pulmonary
cavity who had a non-healing cutaneous ulcer in
the left elbow. (3) Subcutaneous nodules of RA often
occur in pressure sites of extremities giving origin to
ulcers as a result of central necrosis of the nodules due
to vasculitis of small vessels. (3,4) Worthy of note in the
present case study was the high level of anti-cyclic
citrullinated peptide, which is related to extra-articular
manifestations of RA, including nodules. (3) Worthy of
note, under the specialized care of a dermatologist,
the elbow ulcer was cured in 3 weeks.
Cutaneous ulcers occasionally encompass
management challenges; in special the chronic
lesions that pose variable difculties for medical
control in primary care sceneries; besides signicant
burdensome socioeconomic effects and the worst
health-related quality of life of the aged population,
mainly women. (1-5)
1. Rosero Arboleda CK, Loor Zambrano NJ. Cura-
ción de úlcera de pierna en atención primaria.
Rev Med Vozandes. 2020; 31 (1): 117-118.
2. dos Santos VM, Camilo AGO, de Souza LA,
Monteiro LMR, Marinho CS, da Silva de Souza
DW. Marjolin’s ulcer: a challenging complica-
tion of non-healing wounds. Russian Open Med
J. 2015; 4 (3): e0305.
3. Santos VM, Silva RF, Polcheira MF, Gebrim DG,
Pedrosa DL, Cançado ACV. A woman with
rheumatoid arthritis, cavitary pulmonary nodu-
les and skin ulcer. Rev Med Vozandes. 2014; 25
(1-2): 63-66.
4. Bazalin ski D, Wiech P, Baranska B, Binkowska-
Bury M. Use of negative pressure wound thera-
py in a chronic leg wound with coexisting rheu-
matoid arthritis: a case study. J Int Med Res.
2018; 46 (6): 2495-2499.
5. González-Consuegra RV, Verdú J. Quality of life
related with chronic wounds. Gerokomos. 2010;
21 (3): 131-139.