Ulcers in Hypercoagulable States

Abstract

Cutaneous ulcers in hypercoagulable states or thrombophilia are a manifestation of underlying localized ischemia or tissue hypoxia. They can occur in any of the numerous conditions which affect components of Virchow’s triad, viz. hyperviscosity of blood, endothelial injury, and hypercoagulability producing diseases. The commonly encountered thrombophilia-associated ulcers are manifestations of APLA syndrome, cold-associated disease, sickle cell disease, warfarin- and heparin-associated ulcers, hydroxyurea-associated ulcers, cholesterol emboli-associated ulcers, calciphylaxis, and Martorell’s hypertensive ischemic ulcers.

For diagnosis of these ulcers a high index of clinical suspicion is required. They are more likely to occur in atypical sites such as trunk, abdomen, thighs, gluteal region, penis, and breasts. In contrast ulcers due to diabetes mellitus, atherosclerotic ischemia, chronic venous insufficiency, or neurological impairment are exclusively situated in the lower leg and foot region. Thrombophilia-associated ulcers are usually preceded by livedo reticularis and/or atrophie blanche. They are characteristically non-inflammatory and non-responsive to antibiotic therapy. Such cutaneous ulcers may sometimes be the first manifestation of the underlying thrombophilia state. They are often initially mistaken for pyoderma gangrenosum which has a similar clinical presentation. Treatment is aimed at control of the underlying hypercoagulable state along with suitable wound care as required.