Skin ulcers Flashcards
What is the definition of an ulcer?
An abnormal break in the skin or mucous membranes
Which blood system do majority of ulcers originate from?
80% - venous ulcers
Name other causes of ulcers
Arterial insufficiency
Diabetic related neuropathy
Pressure (over a bony prominence) - especially in people that are bed bound
What is the cause of venous ulcers?
Venous insufficiency
How do venous ulcers normally appear?
Shallow
Irregular borders
Granulating base
Characteristically over the medial malleolus
What is the pathophysiology behind venous ulcers?
Valvular incompetence -> venous insufficiency -> impaired venous return -> venous HTN -> WBCs trapped in capillaries and fibrin cuff forms around vessel -> O2 can’t reach tissues -> WBCs become activated -> inflammatory mediators released -> tissue injury, poor healing, necrosis
What are the risk factors for a venous ulcer?
Increasing age
Pregnancy
Pre-existing venous incompetence (incl. varicose veins) or Hx of VTE
Obesity
Physical inactivity
Severe leg injury or trauma
What is the clinical presentation of venous ulcers?
Can be painful (worse at end of day)
Found in the gaiter region
Associated symptoms:
Sensations like
- aching
- itching
- bursting
What might you find on examination of a venous ulcer?
Varicose veins
Ankle swelling (i.e., ankle or leg oedema)
Haemosiderin skin staining
Lipodermatosclerosis (i.e., champagne bottle legs)
Atrophie blanche
What investigations can be done for venous ulcers?
Duplex USS - check for venous insufficiency
ABPI - assess for any arterial component to the ulcer
Swab cultures - if infection is suspected
What is the Mx for venous ulcers?
Conservative
- leg elevation
- increased exercise (to promote calf muscle pump)
- lifestyle changes i.e., weight reduction and improved nutrition
Pharmacological
- only prescribe Abx if suspicious of an infection
- dressings and emollients to maintain surrounding skin health
Surgical
- endovenous techniques or open surgery (improving venous return will allow ulcers to heal)
Main Tx = multicomponent compression bandaging - changed once or twice every week
What % of venous ulcers will heal after 6 months of compression therapy?
30-75%
What must you measure before apply compression bandages?
ABPI
Must be > 0.6
What is the cause of arterial ulcers?
Arterial insufficiency
How do arterial ulcers normally appear?
Small and deep lesions
Well defined borders
Necrotic base
Occur distally at trauma sites and in pressure areas
What are the risk factors for an arterial ulcer?
Risk factors of peripheral vascular disease i.e.,
- smoking
- DM
- HTN
- hyperlipidaemia
- increasing age
- FHx
- obesity
- physical inactivity
What is the clinical presentation of arterial ulcers?
Hx of intermittent claudication (pain when walking) or critical limb ischaemia (pain at rest and/or during the night)
Painful
Develops over time with little to no healing
O/E
- cold limbs
- thickened nails
- necrotic toes
- hair loss
NOTE: also assess for signs of venous insufficiency as patients may have a mix of both
What investigations can be done for arterial ulcers?
Ankle Brachial Pressure Index (ABPI)
> 0.9 = normal
0.8-0.9 = mild
0.5-0.8 = moderate
< 0.5 = severe
Imaging e.g., USS, CTPA, MRA (to assess location of arterial disease)
What is the Mx for arterial ulcers?
Conservative
- lifestyle change advice (e.g., smoking cessation, weight loss, exercise, adopting a healthy diet)
Medical
- pharmacological cardiovascular risk factor modification e.g., statin therapy, antiplatelet drug (e.g., aspirin, clopidogrel), optimisation of BP and BM
Surgical
- Angioplasty (with/without stenting)
- Bypass grafting (usually for more extensive disease)
-Any non-healing ulcers despite a good blood supply may also be offered skin reconstruction with grafts
What is the cause of neuropathic ulcers?
Peripheral neuropathy
What is the pathophysiology behind neuropathic ulcers?
Loss of protective sensation
Repetitive stress and unnoticed injuries form
Painless ulcers form on pressure points of limbs
What are the risk factors for a neuropathic ulcer?
Same as risk factors for peripheral neuropathy
- DM
- Vitamin B12 deficiency
Risk is further compounded by:
- foot deformity
- concurrent peripheral vascular disease
What is the clinical presentation of neuropathic ulcers?
Hx of peripheral neuropathy
Burning/tingling sensation in legs
Single nerve involvement (mononeuritis multiplex, such as CN III or median nerve)
Amotrophic neuropathy (painful wasting of proximal quadriceps)
O/E
Neuropathic ulcers - variable in size, punched out appearance (most common on pressure areas of feet)
Peripheral neuropathy (glove and stocking distribution) with warm feet and good pulses
What investigations can be done for neuropathic ulcers?
BM (either random glucose or HbA1c %) + serum B12 levels.
ABPI +/- duplex = check for arterial disease
Signs of infection = microbiology swab
Any evidence of deep infection (e.g. visible bone or ulcers extending into joints), may warrant an X-ray to assess for osteomyelitis
Assess the extent of peripheral neuropathy = 10g monofilament or Ipswich touch test + with vibration sensation with a 128Hz tuning fork
What is the Mx for neuropathic ulcers?
Diabetic foot clinics - has MDT management
Optimise diabetic control - HbA1c <7%
Improved diet and increased exercise (within limits) should be encouraged
Regular chiropody to maintain good foot hygiene + provide appropriate footwear
Any signs of infection will warrant swabs taken and antibiotics (e.g. flucloxacillin) started
Surgical debridement may be required for ischaemic or necrotic tissue
Extreme cases, necrotic or infected digits = amputation
What is Charcot’s foot?
Neuroarthropathy whereby a loss of joint sensation results in continual unnoticed trauma and deformity occurring
Patients present with swelling, distortion, pain (typically less than may be expected with such a deformity), and loss of function. Any deformity causing the loss of the transverse arch is termed a “rocker-bottom” sole
Requires specialist review for consideration of off-loading abnormal weight, and sometimes immobilisation of the affected joint in plaster.
