Martorell ulcer is a rare and severe skin condition that often causes intense pain. It manifests as a type of leg ulcer, and understanding its nature is important for appropriate management. This condition typically affects individuals with a history of poorly controlled high blood pressure.
Characteristics of Martorell Ulcer
These painful leg ulcers are frequently found on the outer aspect or back of the lower leg, commonly just above the ankle or over the Achilles tendon. They can appear as single lesions or symmetrically on both lower legs.
The ulcers are characterized by extreme pain, often disproportionate to their size and appearance. Initially, they might present as a painful red blister or patch that turns blue before ulcerating. The ulcer’s edge is often inflamed and red-purple, with an irregular shape and a necrotic base, sometimes exposing underlying tendons. Satellite ulcers, which are smaller lesions surrounding the main ulcer, can also occur.
Underlying Causes
The primary cause of Martorell ulcer is its association with long-standing, poorly controlled arterial hypertension. This condition leads to specific changes in the small blood vessels within the skin, particularly the arterioles. High blood pressure causes the walls of these small vessels to thicken, a process known as arteriolosclerosis, which narrows their internal diameter. This narrowing increases resistance to blood flow and reduces the supply of blood and oxygen to the skin tissue, leading to localized skin death, also known as skin infarction.
The reduced blood flow means the vessels cannot adequately open to increase blood supply when needed, further compromising tissue perfusion. While hypertension is a primary factor, other conditions like type 2 diabetes mellitus are frequently associated with Martorell ulcers. Trauma can sometimes trigger the formation of an ulcer, but many also appear spontaneously.
Diagnosis and Identification
Diagnosing a Martorell ulcer involves a thorough clinical assessment, particularly focusing on a patient’s history of long-standing, poorly controlled high blood pressure. Healthcare providers look for the characteristic extremely painful leg ulcer, often located on the outer part of the lower leg or near the Achilles tendon. It is important to distinguish Martorell ulcers from other types of leg ulcers, such as those caused by venous insufficiency or peripheral arterial disease, as their treatments differ significantly. Martorell ulcers typically do not involve significant disease in the larger arteries or veins, and patients usually have palpable pulses in their lower limbs.
To confirm the diagnosis and rule out other conditions, a deep incisional skin biopsy is often performed. This biopsy, taken from the edge of the ulcer and extending into the subcutaneous fat, can reveal thickening of arteriolar walls and sometimes calcium deposits, which are hallmarks of the condition. Imaging techniques like Doppler ultrasound or ankle-brachial index (ABI) measurements can assess arterial flow, helping to confirm the absence of large vessel disease. The rarity of Martorell ulcers and their clinical similarity to other conditions, like pyoderma gangrenosum, can make accurate diagnosis challenging.
Treatment and Long-Term Care
Effective management of Martorell ulcers requires a comprehensive strategy that addresses both the wound itself and the underlying medical conditions. Strict control of blood pressure is a cornerstone of treatment, as even a small reduction in blood pressure can significantly impact ulcer pain and healing. Medications that help open blood vessels, such as calcium channel blockers and ACE inhibitors, are often preferred for blood pressure management.
Pain management is also a primary concern due to the intense discomfort associated with these ulcers. While over-the-counter pain relievers like paracetamol may be sufficient for mild pain, severe cases often necessitate stronger narcotic analgesics. Wound care involves surgical debridement to remove dead tissue, specialized dressings to promote healing, and infection control measures, which may include antibiotics. For larger ulcers, surgical interventions like skin grafting are often performed, which can lead to rapid pain reduction and wound closure.
Long-term care emphasizes consistent follow-up and strict adherence to blood pressure medication to prevent recurrence. Patients are also advised on preventative measures, such as avoiding trauma to the legs and, if applicable, managing associated conditions like diabetes. While the pathology of the arterioles is morphologically fixed, ongoing blood pressure control and wound care are essential for sustained healing and preventing new ulcer development.