Therapeutics in Dermatology
A reference textbook in dermatology

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Hypertensive leg ulcer

8 February 2013, by KLUGER N. & SENET P.


Leg ulcers are especially common in older patients (over the age of 60-65). They have a not-insignificant socioeconomic impact in terms of medical care, young active people stopping work, and a poorer quality of life. They are mainly due to venous insufficiency (70% of cases), arterial insufficiency (20%), or mixed causes (10%) i.e. both venous and arterial involvement [1]. There is a long list of “rare” causes of leg ulcers that includes mainly: necrotic cutaneous vasculitis, calciphylaxis, infections, tumours, pyoderma gangrenosum, medications (hydroxyurea), and rare genetic diseases among others [1].

In 1945, a Spanish cardiologist named Martorell was the first to describe a specific form of leg ulcer that now bears his name. He brought together a series of patients who presented one or several ulcers to the outer aspect of the back of the leg, with associated arterial hypertension (HT) and negative signs: peripheral pulses present, arterial calcifications absent, and chronic venous insufficiency. These ulcers spread quickly, elicited pain spontaneously, and were predominantly seen in women [2, 3]. Since this description was made, it has been postulated that these ulcers could be linked to arteriolosclerosis of the vessels in the dermis [4, 5]. Martorell’s ulcer was soon renamed hypertensive leg ulcer [4], a term which is currently still used for this entity in the English-language literature. More recently, others have proposed the term (Martorell’s) “arteriolosclerotic ulcer” [6], in order to demonstrate that the pathogenesis of Martorell’s ulcer is not associated exclusively with hypertension, as we will go on to discuss. The situation is further complicated by French researchers using the term “angiodermite nécrotique”, a term that describes the clinical appearance, while the English term attempts a pathophysiological approach. Finally, it is important to remember that literal translations of the French term such as “necrotic angiodermatitis” or “necrotizing angiodermatitis” should be avoided as they are wholly incomprehensible to and unknown to researchers [5, 7-10].

Although hypertensive leg ulcers have a characteristic clinical presentation, their pathogenesis is relatively unclear. Hypertensive leg ulcers are still a poorly understood cause of ulceration [11, 12].

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