Ulcers on the medial malleolus with leg hyperpigmentation are most consistent with which condition?

• A. Arterial insufficiency
• B. Chronic venous insufficiency
• C. Lymphedema
• D. Diabetic neuropathic ulcer

Answer: (B)

Ulcers around the medial ankle with brownish leg pigmentation come from chronic venous insufficiency due to venous hypertension. When veins don’t return blood efficiently, fluid and red blood cells seep into the skin, causing iron deposition (hemosiderin) that produces the hyperpigmentation. The ongoing swelling and inflammation lead to skin changes like lipodermatosclerosis and, in the dependent area near the medial malleolus, to venous ulcers that are often shallow and irregular. In contrast, arterial ulcers tend to be painful, cooler, with weak or absent pulses and are usually on the toes or other distal foot areas. Diabetic neuropathic ulcers typically occur on pressure points of the plantar surface and are painless due to sensory loss, while lymphedema can cause swelling and skin changes but does not characteristically present with the hemosiderin pigmentation pattern seen here. This combination of medial malleolar location and hyperpigmentation most strongly indicates chronic venous insufficiency.