Photo Quiz

Persistent Lower-Limb Ulcers in a Patient with Diabetes


Am Fam Physician. 2016 May 1;93(9):783-784.

A 60-year-old woman presented with enlarging ulcers on her ankle and foot. Despite treatment, the ulcers worsened and became more painful, and she noted a new ulcer on her left shin. The problem started as a small ulcerated lesion on the lateral dorsal area of her foot that had developed two years earlier after she bumped into a dresser.

She had a history of diabetes mellitus, hypertension, hyperlipidemia, and myeloproliferative disease. At the time of presentation, her medications included enalapril (Vasotec), metoprolol, furosemide (Lasix), fenofibrate (Tricor), insulin aspart (Novolog), insulin detemir (Levemir), metformin, prednisone, dapsone, topical silver sulfadiazine (Silvadene), and clobetasol cream (Temovate). She was previously taking hydroxyurea and anagrelide (Agrylin) for her myeloproliferative disease. She was a nonsmoker.

On examination, she was afebrile and had ulcers of varying size on her left lower leg over the lateral malleolus and foot (Figures 1 and 2). There were larger ulcerations exposing muscles and tendons, with sharp margins, an undermined and violaceous border, and granulation tissue over the ulcer beds. A smaller area of ulceration was noted in the left midpretibial area. A complete blood count revealed a white blood cell count of 17,200 per mm3 (17.2 × 109 per L). Her blood glucose level was 126 mg per dL (7.0 mmol per L). Findings from Doppler ultrasonography and wound cultures were unremarkable.

Figure 1.

Figure 2.


Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Cutaneous malignancy.

B. Factitial ulcers.

C. Infectious ulcers.

D. Pyoderma gangrenosum.

E. Venous stasis ulcers.

Author disclosure: No relevant financial affiliations.

Address correspondence to Suresh K. Menon, MD, at Reprints are not available from the authors.


show all references

1. Pyoderma gangrenosum. In: Habif TP, et al., eds. Skin Disease: Diagnosis and Treatment. 3rd ed. Edinburgh, Scotland: Elsevier; 2011:624–627....

2. Pyoderma gangrenosum. In: Paller A, Mancini AJ, Hurwitz S. eds. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. 3rd ed. Philadelphia, Pa.: Elsevier Saunders; 2006:665–666.

3. Pyoderma gangrenosum. In: James WD, Berger TG, Elston DM, Odom RB, eds. Andrews' Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, Pa.: Elsevier Saunders; 2006:147–148.

4. Ulcers. In: Marks JG, Miller JJ, Lookingbill DP, eds. Lookingbill and Marks' Principles of Dermatology. 4th ed. Philadelphia, Pa.: Elsevier Saunders; 2006:255–259.

5. Hwang J, Wong E. Non-healing, non-tender ulcer on shin. J Fam Pract. 2015;64(7):421–424.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

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