All Is Not Swell

A 70-year-old man is referred to dermatology after trying “everything else” for problems he has had for at least 15 years. In that time, he has been hospitalized repeatedly for swelling and pain in his legs, with odoriferous drainage.

Despite extensive treatment attempts—multiple antibiotics, oral and topical steroids, and OTC creams—the condition is worsening. In hospital-based chronic wound care clinics, the patient received other treatments, including debridement, whirlpool therapy, and soft compression casts. The latter helped a bit but were too uncomfortable to leave on, as was the compression hose prescribed for him. Two-week hospital stays with oral antibiotics and strict bed rest helped considerably—but only for a short time. Most recently, his primary care provider prescribed a diuretic, which helped for one month.

The patient denies having cancer or deep vein thrombosis (both of which he has been thoroughly checked for), as well as congestive heart failure. He states that almost every morning, upon rising, the swelling in his legs is considerably lessened.

Both legs are swollen, red, and edematous from just below the knees down. Advanced, pebbly, hyperkeratotic plaques cover the lower two-thirds of both legs, favoring the anterior over the posterior portions. Pitting edema is elicited with minimal digital pressure but does not cause any pain.The patient is in no acute distress but is clearly uncomfortable. He has been confined to a wheelchair for years due to back problems; he can barely stand when asked to do so. He is extremely obese.