Cutaneous ulcers Flashcards
How can ulcers be categorized?
- Specific/non specific
- Chronic or acute or acute on chronic
- Inflamatory or non inflammatory
What is an ulcer?
Ulcer is define as loss of continuity in the surface epithelium, underlying tissue can also be affected to varying degrees.
What are specific ulcers?
Specifc caused by a known organism these ulcers usually have well define characteristics
These are formed mainly by certain infective organism
What are non-specific ulcers?
Non specific ulcers are ulcers from various causes and present with similar features
What are chronic ulcers?
Chronic ulcers > 4-6 weeks
What are acute ulcers?
Acute ulcers are ulcers with duration of < 3-4 weeks
What are acute on chronic ulcers?
Acute on chronic ulcers continual injury on a background of chronicity
Repair and destriction occuring at the same time
What are some non-specific ulcers?
- Traumatic ulcers
- Infective ulcers
- Vascular ulcers
- Neurotrophic ulcers (e.g. diabetic foot ulcers)
- Ulcers of metabolic disorders
- Neoplastic ulcers (malignant)
What is an ulcer floor? What are you expected to see on an ulcer floor?
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.
Describe the edge of an ulcer?
it is the junction of the ulcer and the normal skin
What are types of ulcer edges?
- Sloping in non specific ulcers
- Raised and everted in neoplastic ulcers (malignant)
- Punched out syphilitic, neuropathic or pressure ulcers
- Undermined in tuberculous ulcers
What is an ulcer Base? What are types of ulcer Base?
What you feel on palpation, hold the edge or feeling the floor with sterile gloved hand
- Indurated or hard: Malignant, calcifications
- Firm
What are types of ulcer smell?
- Malodourous fishy smell of diabetic foot gangrene
- Smell of decaying flesh from necrotic tissue
Regional structures can experience
- Swelling
- Joint deformity
- Contractures
- Discharging sinus
What is ulcer discharge? What are types of ulcer discharge?
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
What are traumatic ulcers?
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
What can cause pyogenic ulcers?
Cellulitis, boil and carbuncle
What are types of vascular ulcers?
Venous and arterial ulcer
What is a venous ulcer? Who is most prediposed to a venous ulcer?
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
How do you treat venous ulcers?
- 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)
What are the Signs of arterial insufficiency are?
- shiny often hairless skin , cyanotic and cold extremity, brittle nails and lossof nail pulp
- The distal puslse may be absent or diminished
What are arterial ulcers?
- 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
Investigations for arterial ulcers
Arteriography, dupplex uss , ct angiogram
What is the treatment for arterial ulcers?
Is bed rest, transluminal balloon angioplasty, arterial by pass surgery, endoarterctomy
Drugs - vasodilators
Metabolic Ulcers
- Connective tissue disease(systemic lupus, poly arterisis nodusa)
- Hemoglobinopathies
- Ulcerative colitis
- Treatment is addressed to cause of ulcer
Neurotrophic Ulcers
- 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
Neoplastic Ulcers
- Primary skin cancers
- Ulcers from secondary metastasis to the skin
Decubitus/pressure ulcers treatment
– 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
What are some examples of specific ulcers?
- Tuberculous ulcers
- Buruli ulcers
- Tropical ulcers
- Syphilitic ulcers
What are tropical ulcers and what are they caused by?
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
What is a buruli ulcer and what is it caused by?
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
What is a tuberculous ulcer and what is it caused by?
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.
Methods in debridement include
Debridement
Surgical
Enzymatic
Biological method
Osmotic method
Negative presure wound therapy
Skin grafting
Treatment of an ulcer
Bed rest/splinting
Culture sensity antibiotics
Analgesics
Tetanus prophylaxis
Regular dressing changes
Use of desloughing agents/dressing material
Serial debridement/sloughectomy
What are the Investigations of an ulcer?
Investigation
General /specifc
Bacteriolgic studies
Plain radiographs-
Dupplex doppler scan, arteriograph
Chest x rays
Ulcer edge bopsy
Others
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