Guest Editorial: Today's guest editor, is really not a guest at all. Alan Sherman, DPM, CCMEP, is Co-founder of PRESENT e-Learning Systems and developed the PRESENT technology and directs Operations and Content Development. Today Alan shares his surgical expertise on the subject of atrophic skin lesions. Be sure to participate in the one question survey and eTalk at the conclusion of this article, as this is surely one topic we can all benefit from learning more about..

       —Ryan Fitzgerald, DPM, PRESENT RI Associate Editor

Alan Sherman, DPM, CCMEP Co-founder & CEO PRESENT e-Learning Systems

Weeping Atrophic Skin Lesions

HPI: Patient is an 82 year old Caucasian female presenting with a 2 week history of weeping atrophic skin lesions on her anterior legs.  Lesions are asymptomatic  and patient's major complaint is that the large amount of fluid draining from the lesions quickly saturate gauze dressings and then her pant legs.  Within an hour of a dressing change, the distal third of her pant leg can be fully saturated circumferentially.  Pigmented yellow- brown lesions have been present for 3-4 years.

PMH: Pt has a 25 year history of vasculitis, confirmed by positive sural nerve biopsy. She had significant neuropathy symptoms of pain and numbness in legs and feet for this time, non-responsive to gabapentin, attributed to the vasculitis. Symptoms were worse in the evening and were not made worse by exercise. Vascular testing throughout this period revealed mild non-critical limb ischemia with non -critical ABIs.  Patient  has been sedentary for 25 years, due to exercise intolerance  from her neuropathy symptoms and shortness of breath, long attributed to COPD.  Both conditions have been treated with oral prednisone in daily amounts ranging from 4 to 40mg.  Patient is not diabetic but does show renal dysfunction, with serum creatinine running 1.7-2.0.

Figure 1: Right Leg

Figure 2: Right leg close up showing unroofed vesicle heavily draining serous fluid.

Figure 3: Left Leg

Figure 4: Left leg close up.

PMH (continued): In response to progressively worsening shortness of breath, patient underwent a cardiac diagnostic workup which revealed significant worsening aortic stenosis with concomitant COPD attributed to a 40 year 1 pack a day cigarette habit, which she stopped 25 years ago. The aortic valve diameter was critical at .3cm, reduced from a norm of 3cm ( in effect, her tiny aortic valve opening  was only allowing  her left ventricle to output a thin stream of blood into her aorta).  She underwent successful trans apical minimal incision aortic valve replacement in August, and healed with minimal complications.  The surgery did reduce her risk of sudden cardiac death from critical aortic stenosis, and did reduce but not eliminate her shortness of breath.  Surprisingly, however, the surgery completely eliminated her leg and feet "neuropathy" symptoms.  It's been suggested that what was thought to be vasculitic neuropathy all those years was actually atypical claudication and rest pain, caused by the severe aortic stenosis. 

MEDs:

PE: Patient’s anterior legs, the pretibial areas wrapping around medially and laterally, are covered with yellowish-brown atrophic asymptomatic lesions.  A few of the pigmented areas have developed bullae with thin roofs that drain large amounts of clear serous fluid.  Patient’s legs exhibit moderate pitting edema, particularly at the pretibial areas.

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