In their recent report, Best and colleagues [1] provide us with a fresh look at the association between leg ulcers and hydroxyurea therapy. Their conclusion that cessation of hydroxyurea therapy is necessary to achieve healing is nevertheless questionable. Because hydroxyurea is used to treat serious underlying systemic disorders, this approach is often impractical, as illustrated by a patient we recently treated at our wound care center.

A 68-year-old man was referred with many painful, nonhealing ulcers that had been on his right leg for 1 year. The patient had a history of polycythemia vera, diagnosed in 1992, and had received hydroxyurea, 1.5 g/d, plus phlebotomy for 5 years. He also had hypertensive heart disease that was well controlled with extended-release nifedipine, 30 mg/d; metoprolol, 25 mg orally twice daily; furosemide, 20 mg; and aspirin, 325 mg/d. Physical examination revealed good peripheral pulses; slight leg edema; and five ulcers, ranging from 0.3 to 1 cm in diameter. His hemoglobin level was 16.9 g/dL. Results of routine chemistry and serology were unremarkable.

The potential association with hydroxyurea therapy was recognized, and we considered discontinuing this therapy or decreasing the dose. The opinion of the treating hematologist was not to change the dose, however, because the hemoglobin level was still high. Given the patient's mild leg edema, a well-recognized risk factor for leg ulcers, we discontinued therapy with nifedipine because this drug has been associated with leg edema [2]. The metoprolol and furosemide doses were increased to 50 mg twice daily and 40 mg once daily, respectively. Pentoxifylline therapy began, and local wound therapy with silver sulfadiazine cream was given. In less than 4 weeks, all ulcers had healed while the patient still received the same hydroxyurea dose.

Leg ulcers are often multifactorial. In our patient, predisposing factors were hydroxyurea therapy and peripheral edema. In many patients with "hydroxyurea-induced" leg ulcers, other factors, such as poor microcirculation and edema, may be involved. The fact that only a few patients receiving hydroxyurea develop such complication supports this concept.

Our case illustrates that hydroxyurea-associated leg ulcers can be healed even when therapy with the drug is not discontinued. This is further supported by Nguyen and Margolis [3]. We believe that addressing other comorbid predisposing factors for leg ulceration in these patients is sometimes sufficient.