35 | diagnostic pitfalls in cutaneous ulcers: Are they just ulcers?

Introduction. Population ageing, increasing frailty, loss of independence and the growing burden of chronic diseases have made cutaneous ulcers a major healthcare issue, affecting approximately two million people in Italy. Although vascular disorders remain the leading cause of skin ulceration, a broad spectrum of other conditions, including rare diseases, may present with similar clinical features, often leading to diagnostic delays and inappropriate management. The aim of this study was to highlight the main diagnostic challenges encountered in patients with cutaneous ulcers and to emphasize the importance of a comprehensive multidisciplinary approach.Materials and Methods. Several cases of cutaneous ulcers encountered in routine clinical practice were reviewed, including ulcers of neoplastic, infectious, inflammatory, autoimmune and self-inflicted origin. Representative cases of neoplastic ulcers, Leishmania-associated ulcers, factitious dermatitis, inflammatory and occlusive microangiopathies, autoimmune diseases and connective tissue disorders were analyzed. For each case, clinical findings, diagnostic work-up, histopathological features and therapeutic management were evaluated. Extensive clinical photographic documentation supported the analysis.Results. The reviewed cases confirmed that a significant proportion of cutaneous ulcers arise from causes other than vascular disease. Although neoplastic ulcers account for a relatively small percentage of cases, their prompt recognition is crucial because of their prognostic implications. Infectious ulcers may mimic chronic ulcers of different etiologies and require targeted investigations guided by careful history taking and appropriate microbiological and histopathological examinations. Factitious dermatitis is often characterized by a discrepancy between clinical presentation and laboratory or instrumental findings. In such cases, careful assessment and the identification of lesions in easily accessible body areas may raise suspicion of the diagnosis and guide management. Microangiopathic disorders account for approximately 10% of lower-limb ulcers, while autoimmune diseases presenting with ulceration represent a clinically relevant subset of cases. In these settings, ulcers frequently constitute the cutaneous manifestation of an underlying systemic disease. Pyoderma gangrenosum is a notable example and may be associated with inflammatory bowel disease, hematological disorders, hepatic diseases and immunological conditions. In many cases, skin biopsy proved essential for establishing the definitive diagnosis.Conclusions. The evaluation of patients with cutaneous ulcers should extend beyond the lesion itself. A comprehensive medical history, meticulous general and dermatological examination and targeted diagnostic investigations, including skin biopsy when indicated, are essential for achieving an accurate diagnosis. A systematic multidisciplinary approach facilitates the early recognition of potentially complex underlying diseases, allows the implementation of the most appropriate therapeutic strategy and reduces the risk of diagnostic errors, ultimately improving patient outcomes and quality of life.