Arterial Ulcers

An arterial ulcer is tissue loss caused by inadequate arterial blood flow, usually from peripheral arterial disease (PAD). Atherosclerotic narrowing reduces delivery of oxygen, nutrients, and immune cells to the distal limb. It also limits delivery of systemic antimicrobials when infection develops. The result is a wound with little capacity to build granulation tissue, resist infection, or close. A dressing can protect an arterial ulcer, but it cannot correct a critically reduced blood supply. The wound is downstream from the obstruction. Unless perfusion is adequate, aggressive local treatment may enlarge the tissue loss rather than heal it. The classic arterial-ulcer pattern is a distal lower-extremity wound, often on a toe, foot, heel, or around the ankle. The ulcer is commonly deep and sharply demarcated, giving it a “punched-out” appearance. It may contain yellow slough or dry black eschar, produce little exudate, and have little surrounding edema. Granulation tissue is often sparse. Deep wounds may expose tendon or bone. Ischemic pain is often moderate to severe and may be disproportionate to the visible wound. Pain is a useful physiologic clue: poorly...