Novel management of the under diagnosed and difficult to treat arteriosclerotic ulcer of Martorell

Published Date: 20th September 2018

Publication Authors: Brackley P

Abstract

The aim of this case report is to raise awareness and report a novel treatment of an under diagnosed and difficult to treat form of lower limb ulceration, arteriosclerotic ulcer of Martorell. Arteriosclerotic ulcer of Martorell is an intensely painful anterolateral lower leg ulcer with necrosis, that occurs in patients with long-standing hypertension, in the absence of chronic venous insufficiency or clinically significant peripheral arterial disease.1,2 The ulcer often extends rapidly and develops satellite lesions, and secondary infection is common.1 Subcutaneous arteriolosclerosis is seen on histopathology.1,2 A 60-year-old man presented with a 3-month history of an anterolateral left lower leg ulcer with small islands of necrosis, a purple-red violaceous margin, satellite lesions and pain disproportionate to the ulcer size. The course was complicated by recurrent secondary infection. The patient had a 10-year history of hypertension, plus arterial diastolic hypertension of the lower legs and a labile blood pressure ranging between 106 and 149 mmHg (systolic) over 71-94 mmHg (diastolic). Histopathology showed marked intimal fibrosis and hyperplasia of arterioles with almost complete narrowing of the lumen, in the reticular dermis and superficial subcutis. This is the first report of this novel treatment with combined pentoxifylline MR 400 mg tds, doxycycline 100 mg od, negative pressure vacuum dressing followed by a split thickness skin graft. This resulted in complete healing within 3 months. Due to the presence of arteriole narrowing on histology, pentoxifylline was used because of its haemorrheologic properties (aids arterial blood flow). There have been no previous case reports using treatment with either pentoxifylline or doxycycline and a small number of case reports of negative pressure vacuum dressing and successful split thickness skin grafting. We highlight this as an important differential diagnosis of lower leg ulcers. Treatment is challenging and all possible therapeutic agents should be considered to achieve satisfactory healing.

 

Hanna-Bashara, L; Bakshi, A; Brackley, P; West, E. (2018). Novel management of the under diagnosed and difficult to treat arteriosclerotic ulcer of Martorell . British Journal of Dermatology. 179 (S1), 27

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