What would be your next steps in this complex case of a six-month ulcer?

A 76-year-old male with a history of type 2 diabetes, hyperlipidemia, and dementia presents with a six-month history of a painful, non-pruritic ulceration of the right foot. Two months prior, he saw a podiatrist, cardiologist, and his internist, who diagnosed a venous stasis ulcer. At that time, it was weeping a clear to slightly cloudy discharge. He was treated with a silver cream and bandage changes for two weeks but the pain persists. He has a history of onychomycosis and spends four hours a day doing heavy physical labor, such as trimming trees and moving dirty and large rocks.

This case was shared by a internal medicine physician in the Figure 1 community. Here is what other physicians are saying:

Rheumatologist: X-ray of the foot and ankle. Consider fungal arthritis and include sporothrix as well.

Dermatologist: Looks like classic livedo vasculopathy. Stasis is, at best, a minor contributing factor. I would do a hypercoagulation (proteins C&S, factor 5 Leiden, antithrombin 3, antiphospholipd ab, etc.), and probably put him on Trental as a benign starting Rx.

Family medicine physician: Thank you for sharing consider cellulitis and start Abx, good control of his blood glucose. X-ray of the foot and the ankle to rule out osteomyelitis and Osteoarthritis also encourage him to wear stockings to reduce venous states.

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