What is the appropriate management for multiple concentric lesions on the lower extremities?

Management of Multiple Concentric Lesions on Lower Extremities

Immediate Diagnostic Imperative

The presence of multiple concentric lesions on the lower extremities requires urgent vascular assessment with duplex ultrasound as the first-line diagnostic test to rule out chronic venous disease, followed by consideration of rare inflammatory or demyelinating conditions if vascular pathology is excluded. 1

Primary Diagnostic Algorithm

Step 1: Vascular Assessment (Most Common Etiology)

• Duplex ultrasound of the lower extremities is the best initial test for evaluating concentric or circular lesions that may represent lipodermatosclerosis, venous stasis changes, or varicose vein complications 1
• Chronic venous disease affects 25% of adults for C2-C3 stages and 5% for advanced C4-C6 stages, making this the most statistically likely diagnosis 1
• If ultrasound is technically limited (obesity, edema), CT venography or MR venography can be used adjunctively 1

Step 2: Clinical Pattern Recognition

For venous disease patterns:

• Look for bilateral distribution, lower leg predominance, associated edema, skin discoloration (hemosiderin deposition), and history of prolonged standing 1
• Assess for varicose veins, which affect over 2 million adults with advanced disease 1

For non-vascular concentric patterns:

• Consider erythema nodosum leprosum if there are hypopigmented macules, nerve thickening, or history of leprosy treatment 2
• Consider Baló's concentric sclerosis if neurological symptoms (optic neuritis, myelitis) are present, though this typically affects the brain rather than extremities 3

Step 3: Risk Stratification for Intervention

If chronic venous disease is confirmed:

• Treatment is indicated to alleviate symptoms and reduce risk of complications including venous ulceration 1
• Conservative management includes compression therapy as first-line 1
• Endovascular intervention (laser ablation, radiofrequency ablation, or sclerotherapy) is recommended over surgical stripping for saphenous vein insufficiency 1

If peripheral arterial disease is suspected:

• Assess for claudication symptoms, rest pain, or tissue loss 1
• Ankle-brachial index should be obtained 1
• Endovascular procedures are recommended to establish in-line blood flow in patients with nonhealing wounds or gangrene 1

Critical Pitfalls to Avoid

• Do not assume all lower extremity lesions are dermatologic—vascular pathology must be excluded first as it represents the most common and treatable cause 1
• Do not delay vascular imaging if there are signs of venous insufficiency, as progression to venous ulceration significantly increases treatment costs (>$2.5 billion annually in the US) and morbidity 1
• Do not perform surgical intervention without adequate imaging characterization, as anatomic variations are common and affect treatment selection 1
• Be aware that bullous lesions in the context of leprosy treatment may represent erythema nodosum leprosum requiring high-dose corticosteroids or thalidomide, not simple dermatologic management 2

When Vascular Pathology is Excluded

If duplex ultrasound and clinical assessment exclude venous or arterial disease:

• Consider inflammatory conditions (erythema nodosum variants) 2
• Consider metabolic calcification disorders if lesions are firm or calcified 4
• Biopsy of lesional tissue is strongly recommended to establish definitive diagnosis when the etiology remains unclear 1