Malum perforans

Last Updated: 2022-02-04

Author(s): Anzengruber F., Navarini A.

ICD11: -

Mal perforans, neuropathic ulcer.

Ulcerations at pressure-loaded localisations in areas of disturbed pain sensation and skin innervation with a lack of healing tendency.

Common in diabetics and polyneuropathy.

Diseases that can trigger a polyneuropathy:

  • Neuropathic polyneuropathy in peripheral nerve lesions.
  • Traumatic nerve injuries (sciatic nerve, tibial nerve)
  • Diabetes mellitus
  • Leprosy
  • Syphilis (Tabes dorsalis)
  • Alcoholism (Bureau-Barrière syndrome)
  • Amyloid neuropathy
  • Syringomyelia
  • Spinalis-anterior syndrome
  • Congenital insensitivity to pain
  • Trophoneurotic nasal ulcer

Mostly ulcerations occurring in the area of the plantar pressure points.

  • Anamnesis
    • In terms of underlying diseases
  • Clinic
    • Testing for pain sensation in the affected area
    • Probe-to-bone --> probe the ulcer with a sterile stick, if a hard or porous structure is palpated, the test is positive. If this is not the case, then osteomyelitis is unlikely
  • Biopsy
    • To exclude a roden's ulcer (remember, this is not so rare and is sometimes missed for a long time.)
  • If necessary, neurological consultation

Mostly plantar.


If you have a known polyneuropathy, wear adapted footwear and check frequently for pressure sores.

  • Often complete healing is not possible.
  • In some cases, amputation is unavoidable.

  1. Acevedo, A., et al., [Malum perforans diabeticorum: treatment with controlled circulatory blockade and regional intravenous administration of antibiotics]. Wien Med Wochenschr, 1993. 143(7-8): p. 195-8.
  2. Aerden, D., et al., Primary closure with a filleted hallux flap after transmetatarsal amputation of the big toe for osteomyelitis in the diabetic foot: a short series of four cases. Int J Low Extrem Wounds, 2012. 11(2): p. 80-4.
  3. Clohisy, D.R. and R.C. Thompson, Jr., Fractures associated with neuropathic arthropathy in adults who have juvenile-onset diabetes. J Bone Joint Surg Am, 1988. 70(8): p. 1192-200.
  4. Frykberg, R.G., Diabetic foot ulcerations: management and adjunctive therapy. Clin Podiatr Med Surg, 2003. 20(4): p. 709-28.
  5. Heinz, C., [Orthopedic treatment of malum perforans]. Zentralbl Phlebol, 1971. 10(2): p. 114-5.
  6. Janjua, S.A. and Z. Pastar, A case of malum perforans pedis complicated by chronic osteomyelitis. Acta Dermatovenerol Croat, 2015. 23(1): p. 72-3.
  7. Kreyden, O.P., et al., [Case report on therapy with granulocyte stimulating factor in diabetic foot]. Hautarzt, 2001. 52(4): p. 327-30.
  8. Larena-Avellaneda, A., et al., [Diabetic foot syndrome]. Chirurg, 2010. 81(9): p. 849-61; quiz 862.
  9. Meier, L., A. Hollinger, and D. Brunner, [Surgical treatment of diabetic malum perforans by ray resection]. Helv Chir Acta, 1991. 57(5): p. 849-53.
  10. Mian, E., et al., Healing of open skin surfaces with collagen foils. Int J Tissue React, 1992. 14 Suppl: p. 27-34.
  11. Morell, B., [The diabetic foot]. Ther Umsch, 1990. 47(1): p. 55-62.
  12. Morell, B., [The diabetic foot]. Ther Umsch, 1996. 53(12): p. 958-63.
  13. Neubert, H. and M. Pambor, [Acropathia ulceromutilans. Contribution on differential diagnosis of malum perforans]. Dermatol Monatsschr, 1978. 164(2): p. 101-7.
  14. Nishio, K., O. Yamamoto, and J. Tsukahara, Malum perforans pedis caused by spinal canal stenosis and spondylolisthesis. J UOEH, 1984. 6(2): p. 171-6.
  15. Preisz, K., S. Karpati, and A. Horvath, Launois-Bensaude syndrome and Bureau-Barriere syndrome in a psoriatic patient: successful treatment with carbamazepine. Eur J Dermatol, 2002. 12(3): p. 267-9.
  16. Shuman, A.M., Malum perforans in a young girl with spina bifida. J Am Podiatry Assoc, 1970. 60(6): p. 248-9.
  17. Somogyi, T., et al., [Successful management of malum perforans resulting from spina bifida]. Orv Hetil, 1997. 138(9): p. 547-50.
  18. Tesch, M., [Spinal claudication and malum perforans pedis. Late sequela of ankylosing spondylitis (Bechterew disease) with cystic lumbosacral arachnopathy]. Nervenarzt, 1994. 65(12): p. 874-7.