Differential Diagnosis for Ulcerated Punched Out Appearing Ulcers on Bilateral Lower Extremities

• Single most likely diagnosis
  • Venous ulcers: The most common cause of ulcerated, punched-out appearing ulcers on the bilateral lower extremities, typically found on the medial aspect of the legs, just above the ankle. These ulcers are often associated with signs of chronic venous insufficiency such as varicose veins, edema, and skin pigmentation changes.
• Other Likely diagnoses
  • Arterial ulcers: Usually found on the lateral aspect of the legs or on the feet, these ulcers are associated with poor circulation and may be painful, especially at night. They are often linked to atherosclerosis and other vascular diseases.
  • Diabetic foot ulcers: Common in patients with diabetes, these ulcers can appear anywhere on the foot and are often associated with neuropathy, leading to a decrease or loss of sensation, making them less painful than arterial ulcers.
  • Pyoderma gangrenosum: A rare skin condition that can cause ulcers, often with a punched-out appearance. It can be associated with systemic diseases such as inflammatory bowel disease or rheumatoid arthritis.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Vasculitis: Conditions like Wegener's granulomatosis or polyarteritis nodosa can cause ulcers on the lower extremities and are potentially life-threatening if not diagnosed and treated promptly.
  • Infectious causes (e.g., osteomyelitis, septic emboli): Infections can cause ulcers and are critical to identify due to the potential for severe complications, including sepsis and amputation.
• Rare diagnoses
  • Sickle cell ulcers: Found in patients with sickle cell disease, these ulcers are typically seen on the lower extremities and are due to the sickling of red blood cells causing vascular occlusion.
  • Martorell ulcers: Hypertensive ulcers that are rare and usually occur on the lower extremities, associated with uncontrolled hypertension.