What is a Martorell ulcer?

Martorell Ulcer: Definition, Diagnosis and Management

Martorell ulcer is a specific type of painful ischemic leg ulcer caused by arteriolosclerosis in patients with long-standing, poorly controlled hypertension, characterized by pain disproportionate to ulcer size, specific location on the lower extremity, and healing response to blood pressure control.

Clinical Characteristics

Martorell ulcer (also called hypertensive leg ulcer or arteriolosclerotic ulcer) has several distinctive features:

• Patient profile: Typically affects patients aged 40-85 years with long history of poorly controlled hypertension, sometimes with diabetes 1
• Location: Usually appears on the outer (lateral) aspect of the lower leg 2
• Pain: Extremely painful, with pain disproportionate to the size of the ulcer 3
• Appearance: Begins as a small painful area that develops into a slowly expanding superficial necrotic ulcer with a characteristic purpuric rim 1
• Gender predominance: More common in females than males 3
• Prevalence: Represents up to 15% of leg ulcers requiring hospitalization in dermatology wards 1

Pathophysiology

The primary mechanism involves:

• Arteriolosclerosis (narrowing of small arteries) due to long-standing hypertension
• Obliteration of arterioles in the skin and subcutaneous tissue
• Resulting ischemia leads to tissue necrosis and ulceration
• The skin becomes a target organ of uncontrolled hypertension 4

Diagnostic Approach

Diagnosis is based on:

1. Clinical presentation: Extremely painful ulcer with characteristic appearance
2. Medical history: Long-standing hypertension, often poorly controlled
3. Histopathology: Definitive diagnosis requires skin biopsy showing obliteration of arterioles by arteriolosclerosis 4
4. Exclusion of other causes: Must rule out other common causes of leg ulcers such as venous insufficiency, arterial disease, and diabetic ulcers

Diagnostic Criteria

A set of criteria to facilitate diagnosis includes 5:

• History of hypertension
• Extreme pain disproportionate to ulcer size
• Characteristic location on lateral lower leg
• Purpuric border around the ulcer
• Absence of significant peripheral arterial disease
• Histopathological confirmation when needed

Management

Treatment should focus on:

1. Blood pressure control: The cornerstone of management - adequate control of hypertension is essential for healing 4
2. Pain management: Active pain control is crucial as these ulcers are extremely painful 1
3. Wound care:
   • Debridement of necrotic tissue
   • Appropriate dressings to maintain moist wound environment
   • Skin grafting may be necessary for larger ulcers 1
4. Infection control: Management of secondary infections if present 2

Common Pitfalls and Caveats

• Misdiagnosis: Martorell ulcer is frequently underdiagnosed or misdiagnosed as venous ulcer or pyoderma gangrenosum 4
• Delayed treatment: Failure to recognize the condition leads to inadequate treatment and prolonged healing time
• Inadequate pain management: The extreme pain may be underestimated and inadequately treated
• Focusing only on local wound care: Without addressing the underlying hypertension, healing will be significantly delayed
• Unnecessary vascular interventions: Since the pathology is at the arteriolar level, macrovascular interventions may not be beneficial

Prognosis

• Healing is typically slow even with optimal management 1
• Recurrence is possible if hypertension remains poorly controlled
• Long-term blood pressure control is essential for prevention of recurrence

Early recognition of this condition, prompt initiation of antihypertensive therapy, and appropriate wound care are crucial for improving outcomes and reducing the significant morbidity associated with Martorell ulcers.