I was interested in the distribution of “non-trophic cutaneous ulcers” shown on the knuckles and dorsal foot in the case report of a 44-year-old female with multibacillary Hansen's disease or leprosy.1 The case had glove stocking sensory and motor neuropathy and histopathology characteristics of multibacillary Ridley Jopling borderline lepromatous or lepromatous leprosy. The patient was treated with three effective drugs and reportedly had resolution of her neuritis symptoms and dorsal pressure ulcers of her knuckles and upper feet.
Although she may not have had classic neurotrophic plantar ulcers in the soles or weight-bearing surfaces of the foot, her skin ulcers appeared in hyperpigmented areas, where her sandal straps and toe thong might have rubbed the dorsal foot arch and big toe. The dorsal foot ulcers may then have been true neuropathic skin breakdowns from the rubbing of her sandal straps and thong on the hallux of her insensate foot. Likewise, was the upper dorsum foot midline scar a healed ulcer within a hyperpigmented skin strap line encircling the lower ankle and upper foot?
As described by the late Paul Brand, skin ulcers or erosions appear on insensate limbs wherever there is repetitive microtrauma. The ulcers may have evolved from the rubbing of her sandal or shoe straps on her anesthetic feet and ankles. Because the patient had lost the gift of pain, she developed skin ulcerations at the rub sites before she removed her footwear. Although these ulcers were not on her soles or weight-bearing surfaces, the erosions developed on repetitively traumatized skin sites, and therefore, they may be considered, indeed, neurotrophic ulcers, albeit in atypical locations, associated with multibacillary leprosy or Hansen's disease. Thanks again for this unique case report.