40. Skin ulcers Flashcards
History skin ulcers
ulcer: onset, pain, bleeding, size, sensation, skin changes..
Arterial: leg pain intermittent claudication, legs feeling cold? Relieved by putting legs over the side of the bed? chest pain?
Venous: relieved by elevation
Diabetes? How well controlled? Recent HbA1c? What medications..
Pressure: mobility? Recent hospital stay…?
Signs of infection:
examination leg ulcers
look
- SSSS
- borders
- floor and discahrge
feel
- tenderness, temp, edge
- bleed on gentle touch?
move
- move the base ?fixed to deep structures
special tests
- pulses
- sensation
- joint if bony
peripheral vasc, venous, joint exam
invetsigations leg ulcers
ABPI
FBC and CRP for infection
HbA1c, albumin
Charcoal swabs
Skin biopsy for SCC
differentials leg ulcers
Venous ulcers
Arterial ulcers
Neuropathic ulcers eg diabetic foot ulcers
Pressure sores
Marjolins ulcer
SCC
Pyoderma gangrenosum
what are leg ulcers?
Leg ulcers are wounds or breaks in the skin that do not heal or heal slowly due to underlying pathology. They have the potential to get progressively larger and become more difficult to heal over time
pathophysiology venous ulcers
Venous insufficiency –> venous hypertenison –> leaky capillaries –> fibrin cuff formation –> protein and inflamamtory cells get trapped in fibrin cuff –> impedes oxygen and growth factors reaching ulcer –> impairs healing
presentation venous ulcers
Venous ulceration is typically seen above the medial malleolus.
Occur after a minor injury to the leg
Are larger than arterial ulcers
Are more superficial than arterial ulcers
Have irregular, gently sloping border
Are more likely to bleed
Have pain relieved by elevation and worse on lowering the leg
associated with chronic venous changes, such as hyperpigmentation, venous eczema and lipodermatosclerosis
painless/less painful
invetsigations ?venous ulcers
ankle-brachial pressure index (ABPI) is important in non-healing ulcers to assess for poor arterial flow which could impair healing
very important also becuase compression bandaging could worsen arterial disease
interpretation of ABPI
> 1.2: may indicate calcified, stiff arteries. This may be seen with advanced age or PAD
1.0 - 1.2: normal
0.9 - 1.0: acceptable
< 0.9: likely PAD. Values < 0.5 indicate severe disease which should be referred urgently
what is ABPI?
ratio of the systolic blood pressure in the lower leg to that in the arms. Lower blood pressure in the legs (result in a ABPI < 1) is an indicator of peripheral arterial disease (PAD).
Management venous ulcer
- compression bandaging (four layers)
- oral pentoxifylline, a peripheral vasodilator, improves healing rate
Antibiotics are used to treat infection.
Analgesia is used to manage pain (avoid NSAIDs as they can worsen the condition).
what to do when you suspect a mixed ulcer
rf to Vascular surgery
what to do when ulcer not healing depsite treatment / complex
Tissue viability / specialist leg ulcer clinics
Presentation arterial ulcer
Occur on the toes and heel
Typically have a ‘deep, punched-out’ appearance
Painful
There may be areas of gangrene
Cold with no palpable pulses
Are pale colour due to poor blood supply
Are less likely to bleed
Are painful
Have pain is worse on elevating and improved by lowering the leg (gravity helps the circulation)
Management arterial ulcer
The management of arterial ulcers is the same as peripheral arterial disease, with an urgent referral to vascular to consider surgical revascularisation. If the underlying arterial disease is effectively treated, the ulcer should heal rapidly.
Presentation neuropathic/diabetic foot ulcer
plantar surface of metatarsal head and plantar surface of hallux
The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
complication diabetic foot ulcer
Osteomyelitis
pathophysiology pressure ulcers
reduced blood supply and localised ischaemia, reduced lymph drainage and an abnormal change in shape (deformation) of the tissues under pressure
what scoring system can be used to assess a pts risk of developing pressure sores
The Waterlow Score
factors which predispose to pressure ulcers
malnourishment
incontinence
lack of mobility
pain (leads to a reduction in mobility)
management pressure sores
- a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
- consider referral to the tissue viability nurse
- surgical debridement may be beneficial for selected wounds
grades of pressure sores
g1 - Non-blanchable erythema of intact skin
g2 - partial thickness sin loss, looks like abrasion or blister
g3 - full thickness skin loss
g4 - extensive destruction, tissue necrosis, damage to muscle bone or other structures
what is marjolins ulcer
Squamous cell carcinoma
Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
Mainly occur on the lower limb
what is pyoderma gangrenosum
Associated with inflammatory bowel disease/RA
Can occur at stoma sites
Erythematous nodules or pustules which ulcerate
Management diabetic foot ulcer
debridement
“offloading” eg plaster cast to take pressure off ulcer
dressings
first line treatment pyoderma gangrenosum
oral prednisolone
