ULCERSDR.V.MUKESH KRISHNA

Definition

A break in the epithelial continuity

Discontinuity of the skin or mucous membrane which occurs due to the microscopic death of the tissues

Aetiology

Venous Disease (Varicose Veins)Arterial Disease ; Large vessel (Atherosclerosis) or

Small vessel (Diabetes)Arteritis : Autoimmune (Rheumatoid Arthritis, Lupus)TraumaChronic Infection : TB/SyphilisNeoplastic : Squamous or BCC, Sarcoma

Wagner’s Grading of ulcersGrade 0 - Preulcerative lesion/healed ulcerGrade 1 - Superficial ulcerGrade 2 - Ulcer deeper to Subcutaneous tissue

exposing soft tissue or boneGrade 3 - Abscess formation or osteomyelitisGrade 4 - Gangrene of part of tissues/limb/footGrade 5 - Gangrene of entire one area/foot

Classification A. ClinicalB. Pathological

A. Clinical

Spreading : (Edge - Inflamed & Edematous) Healing : (Edge is sloping with healthy red

granulation tissue & serous discharge)Callous : (Floor contains pale unhealthy

granulation tissue with indurated edge)

B.Pathological

1. Nonspecific 2. Specific 3. Malignant

1. Non specific

Traumatic UlcerArterial UlcerVenous UlcerNeurogenic UlcerInfective Ulcer

1. Non specific contd.

Diabetic UlcerTropical UlcerCryopathic UlcerMartorell’s UlcerBazin’s Ulcer

• Traumatic ulcer

1. Mechanical- Dental ulcer on tongue ( jagged tooth )2. Physical- Electrical burn3. Chemical- Application of caustics

Acute, Superficial, Painful, Tender

• Arterial Ulcer

• Caused due to peripheral vascular disease• LL : Atherosclerosis & TAO• UL : Cervical Rib, Raynauds• Chief complaint : Severe Pain• Toes, Feet, Legs & UL Digits

• Venous ulcers

Medial aspect of lower 3rd of lower limbAnkle ( Gaiters Zone ) : Chronic Venous HTNUlcers are PainlessVaricose Veins or Post Phlebitic limb ( PTS )

• Trophic Ulcer

• Pressure Sore or Decubitus Ulcer• Punched out edge with slough on the floor• Ex: Bed Sores & Perforating ulcers• Develop as a result of Prolonged Pressure• Sites : Ischial Tuberosity > Greater Trochanter >

Sacrum > Heel > Malleolus > Occiput

• Tropical ulcer

• Tropical regions : Africa, India, S.America• Trauma or Insect Bite• Fusobacterium fusiformis & Borrelia

vincentii• Abrasions, Redness, Papules & Pustules• Severe Pain

• Diabetic Ulcer

It may be caused due to• Diabetic Neuropathy• Diabetic Microangiopathy• Increased Glucose : Increased Infection• Foot ( Plantar ), Leg, Back, Scrotum, Perineum• Ischemia, Septicemia, Osteomyelitis,

2. Specific

TuberculosisSyphilis Actinomycosis Meleney’s ulcerSoft sore

3. Malignant

Squamous cell caBasal cell caMalignant melanoma

Examination

Inspection PalpationExamination of lymph nodesVascular insufficiency Nerve lesions

INSPECTIONLocation, size, shape, floor, edge, discharge, surround ing area.

PALPATIONTenderness, local rise of temperature, bleeding on touch, consistency of the ulcer, edge, surrounding area - oedema, mobility.

REGIONAL LYMPH NODES SENSATIONS PULSATIONS FUNCTION OF THE JOINT SYSTEMIC EXAMINATION

INSPECTION

LOCATION OF THE ULCERFLOOR OF THE ULCER DISCHARGE FROM THE ULCEREDGESURROUNDING AREA

LOCATION OF THE ULCER

Arterial ulcer Tip of the toes, dorsum of the foot

Long saphenous varicosity with ulcer

Medial side of the leg.

Short saphenous varicosity with ulcer

Lateral side of the leg.

Perforating ulcers Over the sole at pressure points.

Nonhealing ulcer Over the shin

FLOOR OF THE ULCER

DEF : This is the part of the ulcer which is exposed or seen.Red granulation tissue Healing ulcer

Necrotic tissue, slough Spreading ulcer

Pale, scanty granulation tissue

Tuberculous ul cer

Wash-leather slough Gummatous ulcer

DISCHARGE FROM THE ULCER

Serous discharge Healing ulcer

Purulent discharge Spreading ulcer

Bloody discharge Malignant ulcer

Discharge with bony spicules

Osteomyelitis

Greenish discharge Pseudomonas infection

EDGEDEF: This is between the floor of the ulcer and the

margin. The margin is the junction between the normal epithelium and the ulcer.

These two parts represent areas of maximum activity. 3 STAGES Stage of ex-tension. Stage of transition. Stage of repair.

A. Sloping edge All healing ulcers like traumatic ulcers, venous Ulcers

B. Punched out edge

Gummatous ulcers and trophic ulcers.

C. Undermined edge

Tuberculous ulcers

D. Raised edge (beaded edge)

Rodent ulcers or basal cell carcinoma .

E. Everted edge (Rolled out)

Squamous cell carcinoma.

SURROUNDING AREA

Thick and pigmented

Varicose ulcer.

Thin and dark Arterial ulcer.

Red and oedematous

Spreading ulcers like dia betic ulcer.

PALPATIONEDGEBASEMOBILITYBLEEDINGSURROUNDING AREA

EDGEInduration (hardness) of the edge is very

char acteristic of squamous cell carcinoma.

It is said to be a host defense mechanism.

Tenderness of the edge is characteristic of infected ulcers and arterial ulcers.

BASEIt is the area on which ulcer rests.

Marked induration at the base is diagnostic of squamous cell carcinoma.

INDURATION

• The edge, base and the surrounding area should be examined for induration.

Maximum induration Squamous cell carcinoma

Minimal induration Malignant melanoma.

Brawny induration Abscess.

Cyanotic induration Chronic venous congestion as in varicose ulcer.

MOBILITYGentle attempt is made to move the

ulcer to know its fixity to the underlying tissues.

Malignant ulcers are usually fixed, benign ulcers are not.

BLEEDINGMalignant ulcer is friable like a

cauliflower. On gentle palpation, it bleeds.

Granulation tissue as in a healing ulcer also causes bleeding.

SURROUNDING AREA

Thickening and induration is found in squamous cell carcinoma.

Tenderness and pitting on pressure indicates spreading inflammation surround ing the ulcer.

RELEVANT CLINICAL EXAMINATION REGIONAL LYMPH NODES

Tender and enlarged Acute secondary infection.

Non-tender and enlarged

Chronic infection.

Non-tender and hard Squamous cell carcinoma.

Non-tender, large, firm, multiple

Malignant melanoma.

MANAGEMENT

Investigations

1) Complete blood picture: Hb%, TC, DC, ESR, PS2) Urine and blood examination to rule out diabetes3) Chest X-ray - PA. view to rule out P.TB4) Pus for culture/sensitivity5) Lower limb angiography in cases of arterial

diseases6) X-ray of the part to see for Osteomyelitis 7) Biopsy: Non-healing/malignant ulcers

Treatment

Address causeCorrect deficienciesControl pain, infectionDebridement, dressingClosure of defect

TREATMENT OF THE ULCERS

Treatment of Spreading UlcersTreatment of Healing UlcersTreatment of Chronic UlcersTreatment of The Underlying Disease

TREATMENT OF SPREADING ULCERS

Pus Culture/Sensitivity report, Appropriate Antibiotics Solutions to treat the Slough : H₂O₂ & EUSOL -

Edinburgh University Solution (Hypochlorite solution)

Excessive Granulation Tissue (Proud Flesh) : Excision or Application of Copper Sulphate or Silver Nitrate

Repeated Dressings,

TREATMENT OF HEALING ULCER

Regular dressings are done for a few daysAntiseptic creams like Liquid Iodine, Zinc Oxide

or Silver Sulphadiazine.Culture swab is taken to rule out Streptococcus

Haemolyticus ( contraindication for skin grafting )Ulcer is small - Heals by itself ( Epithelialization )

Large - Free Split Skin Graft applied

TREATMENT OF CHRONIC ULCERS

These do not respond to conventional methods of treatment.

The following are tried: Infrared radiation, short-wave therapy, ultraviolet rays

decrease the size of the ulcer. Amnion helps in epithelialization. Chorion helps in granulation tissue. These ulcers ultimately may require skin grafting.

HAVE A GOOD DAY