Cutaneous ulcers

Question 1

How can ulcers be categorized?

Answer 1

1. Specific/non specific
2. Chronic or acute or acute on chronic
3. Inflamatory or non inflammatory

Question 2

What is an ulcer?

Answer 2

Ulcer is define as loss of continuity in the surface epithelium, underlying tissue can also be affected to varying degrees.

Question 3

What are specific ulcers?

Answer 3

Specifc caused by a known organism these ulcers usually have well define characteristics
These are formed mainly by certain infective organism

Question 4

What are non-specific ulcers?

Answer 4

Non specific ulcers are ulcers from various causes and present with similar features

Question 5

What are chronic ulcers?

Answer 5

Chronic ulcers > 4-6 weeks

Question 6

What are acute ulcers?

Answer 6

Acute ulcers are ulcers with duration of < 3-4 weeks

Question 7

What are acute on chronic ulcers?

Answer 7

Acute on chronic ulcers continual injury on a background of chronicity

Repair and destriction occuring at the same time

Question 8

What are some non-specific ulcers?

Answer 8

1. Traumatic ulcers
2. Infective ulcers
3. Vascular ulcers
4. Neurotrophic ulcers (e.g. diabetic foot ulcers)
5. Ulcers of metabolic disorders
6. Neoplastic ulcers (malignant)

Question 9

What is an ulcer floor? What are you expected to see on an ulcer floor?

Answer 9

This that part of the ulcer visible to the eye, that is what you see

Types:
* Full of necrotic tissue,
* Slough (dissolving necrotic tissue usaully white in palely grey in colour
* Full of of pus
* Health granulation tissue –pink, moist, punctate bleeding
* Unhealthy granulation tissue pale and filled with purulent discharge
* Cobble stone appearrance or nodular- malignant transformation
* Bone or exposing artery , tendons, joint cavity submucosa etc.

Question 10

Describe the edge of an ulcer?

Answer 10

it is the junction of the ulcer and the normal skin

Question 11

What are types of ulcer edges?

Answer 11

1. Sloping in non specific ulcers
2. Raised and everted in neoplastic ulcers (malignant)
3. Punched out syphilitic, neuropathic or pressure ulcers
4. Undermined in tuberculous ulcers

Question 12

What is an ulcer Base? What are types of ulcer Base?

Answer 12

What you feel on palpation, hold the edge or feeling the floor with sterile gloved hand

• Indurated or hard: Malignant, calcifications
• Firm

Question 13

What are types of ulcer smell?

Answer 13

• Malodourous fishy smell of diabetic foot gangrene
• Smell of decaying flesh from necrotic tissue

Question 14

Regional structures can experience

Answer 14

• Swelling
• Joint deformity
• Contractures
• Discharging sinus

Question 15

What is ulcer discharge? What are types of ulcer discharge?

Answer 15

What fluid is emernating from the ulcer

Types:
* Serous - ulcers with surrounding edema
* Lymph – ulcers with lymphatic obstruction
* Bloodly discharge – grannulation or malignant
* Pus- infected ulcers
* Pigments- melanoma

Question 16

What are traumatic ulcers?

Answer 16

These are non infective and non specifc ulcers arising from injuries such as avulsion, larceration, burns, irradiation

These are acute in nature and starts of as clean or contaminated depending on the cause

Question 17

What can cause pyogenic ulcers?

Answer 17

Cellulitis, boil and carbuncle

Question 18

What are types of vascular ulcers?

Answer 18

Venous and arterial ulcer

Question 19

What is a venous ulcer? Who is most prediposed to a venous ulcer?

Answer 19

Disease of the venous drainage,
Incompetent valves leading to: venous stasis

• venous hypertension
• common in the lower limbs
• Frequently there is an history of dvt
• Ulcer is very painful
• There is hyperpigmentation of the surrounding skin
• Presence of varicose veins

Question 20

How do you treat venous ulcers?

Answer 20

• Treatment is to improve venous drainage by limb elevation and bed rest
• Elastic compression bandaging and/or compression stocking
• Physiotherapy
• Varicose vein ligation and venous stripping (Trendelenburg procedure)

Question 21

What are the Signs of arterial insufficiency are?

Answer 21

• shiny often hairless skin , cyanotic and cold extremity, brittle nails and lossof nail pulp
• The distal puslse may be absent or diminished

Question 22

What are arterial ulcers?

Answer 22

• Caused by arterial occlusion and insufficiency: Starts as a dry gangrene patch which gradually spread proximally
• Commonest on the distal extremity – toes and fingers
• Common from 50 years above, in patient with diabetes, peripheral vascular disease,
• There are very painfull, and floor is necrotic and dry

Question 23

Investigations for arterial ulcers

Answer 23

Arteriography, dupplex uss , ct angiogram

Question 24

What is the treatment for arterial ulcers?

Answer 24

Is bed rest, transluminal balloon angioplasty, arterial by pass surgery, endoarterctomy
Drugs - vasodilators

Question 25

Metabolic Ulcers

Answer 25

• Connective tissue disease(systemic lupus, poly arterisis nodusa)
• Hemoglobinopathies
• Ulcerative colitis
• Treatment is addressed to cause of ulcer

Question 26

Neurotrophic Ulcers

Answer 26

• Ulcer arises from repeated trauma or prolong pressure on a part due to deminished or absent sensation to that part
• Causes are leprosy, diabetic neuropathy, spinal cord compression and lession, peripheral nerve injury, bit b12 def .
  *Treatment is to address the underlying cause and prevent presure or injuries

Question 28

Neoplastic Ulcers

Answer 28

• Primary skin cancers
• Ulcers from secondary metastasis to the skin

Question 29

Decubitus/pressure ulcers treatment

Answer 29

– 2 hourly turning of patients
– Prevent skin maceration by keeping it dry,
– Use of pressure reliefing devices, e,g air foam mattress, stryker bed,air levitation, ripple bed, other mechanical devices

Question 30

What are some examples of specific ulcers?

Answer 30

• Tuberculous ulcers
• Buruli ulcers
• Tropical ulcers
• Syphilitic ulcers

Question 31

What are tropical ulcers and what are they caused by?

Answer 31

ACUTE SYNERGISTIC ULCERS CAUSED BY bacteriodes fusiformis and aereobic borrellia vincenti
It is common in the tropical and subtropics
Caused by poor personal hygiene, malnutrition and walking bare footed
It start as an acute ulcer from a minor injury, which becomes infected by the above organism

Question 34

What is a buruli ulcer and what is it caused by?

Answer 34

Caused by mycobacterioum ulcerans
Acid fast bacillus
Pre ulcerative/ulcertative lesion
Preulcerative
Papule,nodule,
Plaque
Oedematous lesion
Mixed lesion

Ulcerative
Necrotizing: Organising, Healing
Combine form

Question 35

What is a tuberculous ulcer and what is it caused by?

Answer 35

Skin in areas of tuberculous abscess
It is associated with sattelite sinus, matted lymph nodes and caseous discharge

Bacteriology show acid fast bacilli,

Chest x ray or bone radiograph may show a caseaous lesions.

Question 36

Methods in debridement include

Answer 36

Debridement
Surgical
Enzymatic
Biological method
Osmotic method
Negative presure wound therapy
Skin grafting

Question 37

Treatment of an ulcer

Answer 37

Bed rest/splinting
Culture sensity antibiotics
Analgesics
Tetanus prophylaxis
Regular dressing changes
Use of desloughing agents/dressing material
Serial debridement/sloughectomy

Question 39

What are the Investigations of an ulcer?

Answer 39

Investigation
General /specifc
Bacteriolgic studies
Plain radiographs-
Dupplex doppler scan, arteriograph
Chest x rays
Ulcer edge bopsy
Others

Question 41

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