Skin ulceration Flashcards
What is an ulcer?
An ulcer is a sore on the skin or a mucous membrane, accompanied by the disintegration of tissue. [wiki]
What are the types of ulcer?
Venous, arterial, neuropathic, infective, traumatic, vasculitic.
What is the pathophysiology of venous skin ulcers?
- Incompetent valves in the deep or perforating veins, or previous DVT –>
- Sustained venous hypertension in the superficial veins –>
- Extravasation of fibrinogen through capillary walls–>
- Perivascular fibrin deposition.
Give 3 risk factors for venous skin ulcers.
DVT Varicose veins (incompetent veins) Increasing age Lower leg oedema Venous eczema Lipodermasclerosis
Describe the presentation of venous ulcers.
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
Describe the peripheral pulse in venous ulcers.
Normal peripheral pulse.
Describe the cap refill in venous ulcers.
< 3 sec (normal <2s)
What does the ABI measure and what does it show for venous ulcers?
Ankle brachial index = Ankle BP: arm BP ratio, measured using a Doppler study. Normal (0.8-1) in venous ulcers.
What can cause brown pigmentation in venous ulcers?
Haemosiderin, an intracellular iron storage complex.
Describe the management of venous ulcers.
Compression bandaging
Leg elevation
Diuretics to reduce oedema
Antibiotics, analgesia, support stockings for life
Why do arterial ulcers form?
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.
Give 3 risk factors for arterial ulcers.
Arterial disease eg atherosclerosis
Smoking
Hypercholesterolaemia
DM
Describe the presentation of arterial ulcers.
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
Describe the pulse in arterial ulcers
Absent
Describe the cap refill in arterial ulcers
> 3 sec (normal <2 sec so this is high)
What is the ABI in arterial ulcers and why?
<0.75 (low) - arterial insufficiency. This is the key investigation. (Doppler study)
Describe the management of arterial ulcers
Vascular reconstruction (never compression banding)
Why is compression banding inappropriate for arterial ulcers?
This further impedes blood flow.
What causes neuropathic ulcers?
The person cannot feel their feet so repeated trauma results in infected ulcers. Usually due to diabetic neuropathy.
What can cause neuropathic ulcers apart from diabetic neuropathy?
Nerve injury
Viral infection such as shingles
Excess alcohol consumption, medications
[nhs]
Describe the presentation of neuropathic ulcers.
Site: pressure sites of foot - heel, metatarsal heads
Ulcers: variable size, usually surrounded by callus
Skin: warm
Pain: often painless (neuropathy)
Describe the peripheral pulse in neuropathic ulcers
Normal
Describe the management of neuropathic ulcers.
Clean ulcer Treat infections Remove pressure from area Appropriate footwear control DM podiatry.
What causes vasculitic ulcers?
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.
Give 3 risk factors for vasculitic ulcers.
Angiitis RFs: 50% idiopathic Drugs Inflammatory disease Infection Malignant disease [pts]
Describe the skin changes in vasculitic ulcers.
Haemorrhagic papules; pustules, nodules and plaques.
May erode and ulcerate
Purpuric non-blanching lesions
Mottled pattern
Give 2 extradermal symptoms of vasculitic ulcers.
Pyrexia
Arthralgia
How are vasculitic ulcers treated?
Analgesia, support stockings, steroids eg prednisolone.
