5.2.3 Neuropathic Ulcers

Grading & Level of Importance: C




Neurotrophic ulcer, Acroosteopathia ulceromutilans, malum perforans.


Prevalence up to 50 (6-51) % of patients with diabetes during their lifetime. There are no published statistics on the epidemiology of malum perforans in late-stage syphilis, leprosy or nerve injuries. The alcohol-induced malum perforans occurs exclusively in males with a distinct genetic disposition.


Ulceration in areas of physical/mechanical pressure on the basis of polyetiologic sensory polyneuropathy. Disturbance of the “trophic of the tissue”, not of the venous or arterial circulation.

Aetiology & Pathogenesis

Sensory polyneuropathy with preference of thin nerve fibers on the basis of a genetic predisposition. Dissociated sensation deficit with loss of thermo-, pressure- and pain-sensation. Potential causes are:


  • Metabolic disorders: diabetes; rarely amyloidosis

  • Alcohol (Bureau-Barrière-syndrome)

  • Infectious:

  • Syphilis (III/IV)

  • Leprousy

  • Nerve trauma (Ischias)

  • Hereditary (Thevenard-syndrome)

Signs & Symptoms

Loss of thermo- and pressure sensitivity and of pain. Formation of a localized hyperkeratosis with a hemorrhagic bulla and finally ulceration. Fractures of the underlying bones (foot or toes) (Acroosteopathia ulceromutilans). Hyperthermy of the involved limb with an- (diabetes) or hyperhidrosis (alcoholic polyneuropathy).


Areas of mechanical pressure; preferentially heel and ball of the foot and toes.


According to aetiology.

Laboratory & other workups

Search for underlying disease. Imaging methods (x-ray; MRI). Determination of the (severely reduced) nerve conduction velocity. Neurologic status. Orthopedic counseling.


Not indicated.


Chronic; depending on the underlying disorder.


Superinfection; (painless) fractures; mutilation.


Clinical picture of painless ulcer in conjunction with an underlying disorder (see aetiology).

Differential diagnosis

Prevention & Therapy

Prevention: avoidance and treatment of the aetiopahogenetic background.


Since the polyneuropathy is irreversible (vitamin B-complex may be supportive in some instances), the only effective treatment is avoidance of pressure by appropriate orthopedic shoes. Plastic reconstructive surgery must be an exception, since the benefit is only temporary.


Cooperation with internal medicine and orthopedics.

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