Clinical Presentation and Risk Factor of Cruris Ulcer in Sanglah

General Hospital, Denpasar, Indonesia

Made Wardhana

, Martina Windari

, Sissy

, Hasri Dewi

, Vebryanti Karna

, L. M. Rusyati

Department of Dermatology and Venereology, Faculty of Medicine, Udayana University/

Sanglah General Hospital, Bali

Corresponding author

Keywords: ulcus cruris, clinical pretersation, risk factors

Abstract: Leg ulcers often referred to as cruris ulcers refer to skin discontinuities with the loss of the epidermis, and

part of the dermis or the entire dermis, generally occurring in the lower limbs due to various disease

processes and other causative factors. Cruris ulcers can also be defined as leg ulcers that do not show signs

of healing in less than four weeks. The exact cause has not been acknowledged, but some conditions such as

illness can play a role in causing this disease. Some theories related to the diseases underlying the cruris

ulcer are venous disorders around 80%, arterial disorders around 5%, and trauma or infections around 5%.

The cruris ulcer due to neuropathic disease occurs in about 5% of cases, as a result of peripheral neuropathy,

usually in patients with diabetes and leprosy, local paresthesias, or lack of sensation, at pressure points on

the feet can cause prolonged microtrauma, eventually ulceration. Other causes are systemic disease and

malignancy. Ulcers are often preceded by a disruption of venous flow (chronic venous insufficiency) which

then develops into static dermatitis, which in turn develops into small ulcers that are increasingly larger.

Cruris ulcers are usually chronic, occur in overweight patients, pregnancy, smoking, using tight clothing,

and long-standing physical activities.

In this retrospective descriptive study, clinical forms were observed, and several factors were considered as

triggers for the leg ulcers. In the present study, the cruris ulcer was caused by the weakness of the vein 18

(58.1%), neuropathic 6 (19%), arterial 4 (12.9%), and infection/trauma 3 (9.8%).

1 INTRODUCTION

Leg ulcers often referred to as cruris ulcers refer to

skin discontinuities with the loss of the epidermis,

and part of the dermis or the entire dermis, generally

occurring in the lower limbs due to various disease

processes, such as chronic venous insufficiency.

Cruris ulcers are usually chronic, occur in

overweight patients, pregnancy, smoking, using tight

clothing, and long-standing physical activities.

Cruris ulcers can also be defined as leg ulcers that

do not show signs of healing in less than four weeks.

It is often preceded by chronic venous insufficiency

and then develops into static dermatitis and

eventually becomes a small ulcer.

Classification of cruris ulcer, varies greatly, but

in principle, are: 1. Tropic ulcer, due to trauma,

hygiene and nutrition, and infection by Bacillus

fusiformis and Borreliaviincentii, 2. Varikosum

ulcer, due to chronic venous insufficiency, 3.

Arteriosum ulcer, caused by disturbed circulation

which results in arterial failure in sending oxygen

and nutrients to the lower limbs, resulting in cell

death and tissue damage, and 4. Neurotrophic ulcers,

due to peripheral neuropathy, and nerve damage,

causing disturbances in the legs, due to increased

pressure or mild injury, the most common cause of

peripheral neuropathy is diabetes and morbus

Hansen.

This disease is generally caused by several

conditions as follows; chronic venous insufficiency

- around 80%, arterial disorders - around 15%, and

other causes (including diabetes and rheumatoid

arthritis, systemic diseases and malignancies) -

around 5%.

Wardhana, M., Windari, M., Sissy, ., Dewi, H., Karna, V. and Rusyati, L.

Clinical Presentation and Risk Factor of Cruris Ulcer in Sanglah General Hospital, Denpasar, Indonesia.

DOI: 10.5220/0009991204450448

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 445-448

ISBN: 978-989-758-469-5

445

2 METHODS

In this study using retrospective observations, we

observed medical records of patients diagnosed with

cruris ulcer from 2015-2018. Thirty-one cases of

cruris ulcer were observed. All patients aged

between 45-65 years. Several factors are listed as

possible trigger factors such as family history,

activity, obesity, and underlying disease. Also noted

clinical forms such as; form of ulcer, ulcer size,

number of ulcers, and location of ulcer.

3 RESULTS

A total of 31 cases of cruris ulcer were observed, all

patients aged between 45-65 years. Eleven cases

(61.1%) were preceded by static dermatitis (venous

insufficiency), in nine female patients who had a

body mass index above 26. Eighteen cases (58.1%)

due to chronic venous insufficiency, 6 cases (19.4%)

with neuropathic (3 with morbus Hansen, 3 with

diabetic ulcers), 4 cases with arterial insufficiency

ulcers and 3 cases (9.8%) due to infections such as

cellulitis/erysipelas. Factors that play a role in the

cruris ulcer can be seen in Table 1. below.

Table 1: Clinical presentation and risks

Venous(%)

18 (58.1)

Arterial (%)

4 (12.9)

Neuropathic (%)

6 (19.4)

Infection/Injury(%)

3 (9.8)

Gender

Male (%) 4 (12.9) 2 (6.4) 1(3.2) 2(6.4)

Female (%) 14 (45.2) 2 (6.4) 5(16.1) 1(3.2)

Age

< 50 years (%) 3(9.7) 1(3.2) 2(6.4) 1(3.2)

> 50 years (%) 15(48.4) 3(9.7) 4(12.9) 2(6.4)

Lama sakit (durasi)

1-5 tahun 5(16.1) 1(3.2) 1(3.2) 2(6.4)

> 5 tahun 13(41.9) 3(9.7) 5(16.1) 1(3.2)

Localization (dominant)

Area I-Tungkai (%) 5(16.1) 1(3.2) 1(3.2) --

Area II-Pedis (%) 10(32.2) 2(6.4) 2(6.4) 3(9.7)

Area III-Plantar pedis (%) 3(9.7) 1(3.2) 3(9.7) --

Clinical features

Round shape 5(16.1) 1(3.2) 2(6.4) 1(3.2)

Geographical shape 13(41.9) 3(9.7) 4(12.9) 2(6.4)

Number of ulcers

Single 7(22.6) 1(3.2) 4(12.9) 2(6.4)

Multiple 11(35.5) 3(9.7) 2(6.4) 1(3.2)

Size of ulcer

Mild < 2 cm

(%) 6(19.3) 1(3.2) 1(3.2) --

Moderate 2-5 cm

(%) 9(29.0) 2(6.4) 3(9.7) 1(3.2)

Severe > 5 cm

(%) 3(9.7) 1(3.2) 2(6.4) 2(6.4)

Family history

Yes (%) 10(32.2) 2(6.4) 3(9.7) 2(6.4)

No (%) 8(25.8) 3(9.7) 3(9.7) 1(3.2)

Activity

Standing > 8 hrs (%) 11(35.5) 3(9.7) 3(9.7) --

Standing < 8 hrs (%) 7(22.6) 1(3.2) 3(9.7) 3(9.7)

Obese (BMI)

BMI < 25 5 1(3.2) 2(6.4) 1(3.2)

BMI > 25 13(41.9) 3(9.7) 4(12.9) 2(6.4)

Underlying diseases

Static dermatitis/venous 8(25.8) 2(6.4) 3(9.7) 1(3.2)

Diabetes 3(9.7) 1(3.2) 2(6.4) 2(6.4)

Hipertensi 7(22.6) 1(3.2) 1(3.2) --

Vascuilardoppler

(ABPI)

(No data)

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

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

Figure 1. Clinical presentation

4 DISCUSSION

Leg ulcers often referred to as cruris ulcers refer to

skin discontinuities with the loss of the epidermis,

and part of the dermis or the entire dermis, generally

occurring in the lower limbs and soles of the feet

caused by various disease processes. The most

common cause is chronic venous insufficiency.

Classification of cruris ulcer, varies greatly, but in

principle, are: 1. Tropic ulcer, due to trauma,

hygiene and nutrition, and infection by Bacillus

fusiformis and Borreliaviincentii, 2. Varikosum

ulcer, due to chronic venous insufficiency, 3.

Arteriosum ulcer, caused by disturbed circulation

which results in arterial failure in sending oxygen

and nutrients to the lower limbs, resulting in cell

death and tissue damage, and 4. Neurotrophic ulcers,

due to peripheral neuropathy, and nerve damage,

causing disturbances in the legs, due to increased

pressure or mild injury, the most common cause of

peripheral neuropathy is diabetes and morbus

Hansen.

Cruris ulcers are usually chronic, occur in

overweight patients, pregnancy, smoking, using tight

clothing, and long-standing physical activities. A

total of 31 cases of cruris ulcer were observed, all

patients aged between 45-65 years. Eleven cases

(61.1%) were preceded by static dermatitis (venous

insufficiency), in nine obese female patients.

Eighteen cases (58.1%) due to chronic venous

insufficiency, 6 cases (19.4%) with neuropathic (3

with morbus Hansen, 3 with diabetic ulcers), 4 cases

with arterial insufficiency ulcers and 3 cases (9.8%)

due to infections such as cellulitis/erysipelas.

In this retrospective descriptive study,

clinical forms were observed and several factors

were considered as triggers for the leg ulcer. In this

study the cruris ulcer was caused by the weakness of

veins 18 cases (58.1%), neuropathic 6 cases (19%),

arterial 4 cases (12.9%), and infection/trauma 3

cases (9.8%). Venous disease is the main causative

Clinical Presentation and Risk Factor of Cruris Ulcer in Sanglah General Hospital, Denpasar, Indonesia

447

factor for more than two-thirds of all leg ulcers:

Venous disease - about 80% of leg ulcers, Arterial

disease - about 15% of leg ulcers, and other causes

(including diabetes and rheumatoid arthritis and

some rare conditions) - about 5% of cruris ulcers. In

9 female patients and 4 male, who had a body mass

index above 26, eleven patients have long-standing

physical activities, (35.5%) with standing activities

more than 8 hours a day.

5 CONCLUSION

Most cases of cruris ulcers in this study were due to

chronic venous insufficiency, and neuropathic. The

clinical features are geographic, multiple, and have a

history of more than five years of ulcers. Obesity

and long-standing physical activities also play a role

in the cruris ulcer. The therapy given is generally

conventional, namely with ulcer treatment, and also

with some other modalities, such as PRP (platelet-

rich plasma) and Low Laser Biostimulation.

ACKNOWLEDGMENTS

I would like to thank our patients from the

Dermatology Department, Sanglah General Hospital,

for their technical help. I also thank all patients who

kindly participated in the study.

CONFLICT OF INTEREST

The authors declare that they have no conflict of

interest related to the publication of this manuscript.

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