Derm Flashcards
Pressure sores
Def, path, sx, ix, mx
Pressure sores are localised areas of tissue damage caused by prolonged pressure or friction, typically occurring over bony prominences. They can range from superficial skin damage to deep tissue injury and are often associated with
immobility and prolonged pressure on specific body areas.
Path:
1. Pressure and Tissue Ischemia: Continuous pressure or friction reduces blood flow to affected areas, leading to tissue ischemia (lack of oxygen and nutrients.
2. Cellular Damage: Lack of oxygen and nutrients causes cellular damage, primarily affecting skin and underlying tissues.
3. Inflammation: Injured tissues trigger an inflammatory response, which can further exacerbate tissue damage.
4. Necrosis and Ulceration: Severe tissue damage may lead to tissue necrosis, ultimately resulting in an open wound or ulcer.
Sx:
• Skin changes, ranging from redness to skin breakdown and ulceration.
• Pain or discomfort at the affected site.
• Warmth or coolness over the affected area.
• Swelling or induration (hardening) of the surrounding tissue.
• Open sores or wounds with varying degrees of tissue involvement
Ix:
Pressure sores are diagnosed clinically in correlation to their appearance, however additional investigations which may form part of their management include:
• Imaging studies (e.g. X-rays, MRI) to assess underlying tissue involvement
• Blood tests (e.g. full blood count, serum albumin) to assess overall health and nutritional status
• Wounds should only be swabbed if infection is suspected
Mx:
1. Pressure Relief: Minimising pressure on affected areas through repositioning, specialised mattresses, and cushions.
2. Wound Care: Appropriate wound cleaning, debridement, and dressing changes. Regular review of wounds to monitor any changes in size and appearance.
3. Nutritional Support: Ensuring adequate nutrition and hydration, addressing deficiencies.
4. Pain Management: Managing pain associated with pressure sores.
5. Infection Control: Preventing and treating wound infections.
6. Surgical Interventions: In some cases, surgical procedures (e.g. flap reconstruction) may be necessary.
Venous vs arterial ulcers
Site, rf, sx, description
Neuropathic ulcers
Def, rf, sx, description, ix, mx
A neuropathic ulcer is due to peripheral neuropathy
There is a loss of protective sensation. which leads to
repetitive stress and unnoticed injuries forming,
resulting in painless ulcers forming on the pressure
points on the limb. Concurrent vascular disease will
often contribute to their formation and reducing healing potential.
Risk Factors:
Neuropathic ulcers can develop from any peripheral
neuropathy condition, the most common being
diabetes mellitus and B12 deficiency.
Ulcer risk is further compounded by any foot
deformity or concurrent peripheral vascular disease
Sx:
• Warm feet and pulses still present (unless element of concurrent arterial disease).
• Burning/tingling in legs (paraesthesia - painful neuropathy)
• Occur most commonly on sites increased pressure points on the bottom of the feet. (e.g. metatarsal
heads or heels).
• Signs of peripheral neuropathy (classically in a ‘glove and stocking’ distribution
Appearance:
• Ulcers are variable in size and depth, with a “punched out appearance”. These ulcers are often
neglected because they don’t cause pain.
• May appear pink/red or brown/black while the borders look like a deep punched out.
• The surrounding skin is often calloused and dry and cracked.
• The wound is red and warm in the early stages, may progress to eschar and gangrene in later stage
Ix:
• Blood glucose (random or HbA1c %)
• Serum B12 levels
• Look for signs of concurrent arterial disease and assess with ABPI +/- doppler duplex.
• Wound swab if deep infection deep infection (e.g. visible bone or ulcers extending into joints),
• may warrant an X-ray to assess for osteomyelitis.
• Peripheral neural examination
• Assess the extent of peripheral neuropathy which can be done using the 10g monofilament or
Ipswich touch test, along with testing vibration sensation with a 128Hz tuning fork.
Mx:
• Referral to diabetic foot clinics for patients with neuropathic ulcers, where they are managed via a
full multidisciplinary (MDT) team.
• Diabetic control should be optimised, targeting HbA1c <7%.
• Improved diet and increased exercise and any cardiovascular risk factors present managed
accordingly.
• Regular chiropody to maintain good foot hygiene and appropriate footwear provided (e.g. non-
weight bearing shoes).
• Antibiotics based on wound swab culture and sensitivity result (e.g. flucloxacillin)
• Ischaemic or necrotic tissue may require surgical debridement or amputation
