Skin ulceration

Question 1

What is an ulcer?

Answer 1

An ulcer is a sore on the skin or a mucous membrane, accompanied by the disintegration of tissue. [wiki]

Question 2

What are the types of ulcer?

Answer 2

Venous, arterial, neuropathic, infective, traumatic, vasculitic.

Question 3

What is the pathophysiology of venous skin ulcers?

Answer 3

1. Incompetent valves in the deep or perforating veins, or previous DVT –>
2. Sustained venous hypertension in the superficial veins –>
3. Extravasation of fibrinogen through capillary walls–>
4. Perivascular fibrin deposition.

Question 4

Give 3 risk factors for venous skin ulcers.

Answer 4

DVT
Varicose veins (incompetent veins)
Increasing age
Lower leg oedema
Venous eczema
Lipodermasclerosis

Question 5

Describe the presentation of venous ulcers.

Answer 5

Pain: minimal
Site: Above medial and lateral malleoli
Ulcer: large, shallow, irregular, exudative
Edges: sloping, gradual.
Skin: hot (Erythema), may have hair
Wound bed: covered with slough
Oedema, brown varicose veins

Question 6

Describe the peripheral pulse in venous ulcers.

Answer 6

Normal peripheral pulse.

Question 7

Describe the cap refill in venous ulcers.

Answer 7

< 3 sec (normal <2s)

Question 8

What does the ABI measure and what does it show for venous ulcers?

Answer 8

Ankle brachial index = Ankle BP: arm BP ratio, measured using a Doppler study. Normal (0.8-1) in venous ulcers.

Question 9

What can cause brown pigmentation in venous ulcers?

Answer 9

Haemosiderin, an intracellular iron storage complex.

Question 10

Describe the management of venous ulcers.

Answer 10

Compression bandaging
Leg elevation
Diuretics to reduce oedema
Antibiotics, analgesia, support stockings for life

Question 11

Why do arterial ulcers form?

Answer 11

Mainly due to peripheral artery disease in which there is poor blood flow to the capillaries in the lower extremities which means they are easily damaged and do not repair.

Question 12

Give 3 risk factors for arterial ulcers.

Answer 12

Arterial disease eg atherosclerosis
Smoking
Hypercholesterolaemia
DM

Question 13

Describe the presentation of arterial ulcers.

Answer 13

Ulcers: punched out, small
Pain: Painful, worse when elevated
Feet and anterior shin.
Edges: well-defined
Wound bed: covered with slough and necrotic tissue.
Exudate: minimal.
Skin: cold, shiny, pale, hairless

Question 14

Describe the pulse in arterial ulcers

Answer 14

Absent

Question 15

Describe the cap refill in arterial ulcers

Answer 15

> 3 sec (normal <2 sec so this is high)

Question 16

What is the ABI in arterial ulcers and why?

Answer 16

<0.75 (low) - arterial insufficiency. This is the key investigation. (Doppler study)

Question 17

Describe the management of arterial ulcers

Answer 17

Vascular reconstruction 
(never compression banding)

Question 18

Why is compression banding inappropriate for arterial ulcers?

Answer 18

This further impedes blood flow.

Question 19

What causes neuropathic ulcers?

Answer 19

The person cannot feel their feet so repeated trauma results in infected ulcers. Usually due to diabetic neuropathy.

Question 20

What can cause neuropathic ulcers apart from diabetic neuropathy?

Answer 20

Nerve injury
Viral infection such as shingles
Excess alcohol consumption, medications
[nhs]

Question 21

Describe the presentation of neuropathic ulcers.

Answer 21

Site: pressure sites of foot - heel, metatarsal heads
Ulcers: variable size, usually surrounded by callus
Skin: warm
Pain: often painless (neuropathy)

Question 22

Describe the peripheral pulse in neuropathic ulcers

Answer 22

Normal

Question 23

Describe the management of neuropathic ulcers.

Answer 23

Clean ulcer
Treat infections
Remove pressure from area
Appropriate footwear
control DM
podiatry.

Question 24

What causes vasculitic ulcers?

Answer 24

Vasculitis, associated which chronic inflammatory disorders such as RA and SLE. Cutaneous vasculitis can be isolated or associated with vasculitis in other organs. Most common cutaneous small vessel vasculitis is Leucocytoclastic vasculitis/angiitis.

Question 25

Give 3 risk factors for vasculitic ulcers.

Answer 25

Angiitis RFs:
50% idiopathic
Drugs
Inflammatory disease
Infection
Malignant disease
[pts]

Question 26

Describe the skin changes in vasculitic ulcers.

Answer 26

Haemorrhagic papules; pustules, nodules and plaques.
May erode and ulcerate
Purpuric non-blanching lesions
Mottled pattern

Question 27

Give 2 extradermal symptoms of vasculitic ulcers.

Answer 27

Pyrexia

Arthralgia

Question 28

How are vasculitic ulcers treated?

Answer 28

Analgesia, support stockings, steroids eg prednisolone.