Skin ulcers

Question 1

What is the definition of an ulcer?

Answer 1

An abnormal break in the skin or mucous membranes

Question 2

Which blood system do majority of ulcers originate from?

Answer 2

80% - venous ulcers

Question 3

Name other causes of ulcers

Answer 3

Arterial insufficiency

Diabetic related neuropathy

Pressure (over a bony prominence) - especially in people that are bed bound

Question 4

What is the cause of venous ulcers?

Answer 4

Venous insufficiency

Question 5

How do venous ulcers normally appear?

Answer 5

Shallow

Irregular borders

Granulating base

Characteristically over the medial malleolus

Question 6

What is the pathophysiology behind venous ulcers?

Answer 6

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

Question 7

What are the risk factors for a venous ulcer?

Answer 7

Increasing age

Pregnancy

Pre-existing venous incompetence (incl. varicose veins) or Hx of VTE

Obesity

Physical inactivity

Severe leg injury or trauma

Question 8

What is the clinical presentation of venous ulcers?

Answer 8

Can be painful (worse at end of day)

Found in the gaiter region

Associated symptoms:
Sensations like
- aching
- itching
- bursting

Question 9

What might you find on examination of a venous ulcer?

Answer 9

Varicose veins

Ankle swelling (i.e., ankle or leg oedema)

Haemosiderin skin staining

Lipodermatosclerosis (i.e., champagne bottle legs)

Atrophie blanche

Question 10

What investigations can be done for venous ulcers?

Answer 10

Duplex USS - check for venous insufficiency

ABPI - assess for any arterial component to the ulcer

Swab cultures - if infection is suspected

Question 11

What is the Mx for venous ulcers?

Answer 11

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

Question 12

What % of venous ulcers will heal after 6 months of compression therapy?

Answer 12

30-75%

Question 13

What must you measure before apply compression bandages?

Answer 13

ABPI

Must be > 0.6

Question 14

What is the cause of arterial ulcers?

Answer 14

Arterial insufficiency

Question 15

How do arterial ulcers normally appear?

Answer 15

Small and deep lesions

Well defined borders

Necrotic base

Occur distally at trauma sites and in pressure areas

Question 16

What are the risk factors for an arterial ulcer?

Answer 16

Risk factors of peripheral vascular disease i.e.,
- smoking
- DM
- HTN
- hyperlipidaemia
- increasing age
- FHx
- obesity
- physical inactivity

Question 17

What is the clinical presentation of arterial ulcers?

Answer 17

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

Question 18

What investigations can be done for arterial ulcers?

Answer 18

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)

Question 19

What is the Mx for arterial ulcers?

Answer 19

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

Question 20

What is the cause of neuropathic ulcers?

Answer 20

Peripheral neuropathy

Question 21

What is the pathophysiology behind neuropathic ulcers?

Answer 21

Loss of protective sensation

Repetitive stress and unnoticed injuries form

Painless ulcers form on pressure points of limbs

Question 22

What are the risk factors for a neuropathic ulcer?

Answer 22

Same as risk factors for peripheral neuropathy
- DM
- Vitamin B12 deficiency

Risk is further compounded by:
- foot deformity
- concurrent peripheral vascular disease

Question 23

What is the clinical presentation of neuropathic ulcers?

Answer 23

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

Question 24

What investigations can be done for neuropathic ulcers?

Answer 24

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

Question 25

What is the Mx for neuropathic ulcers?

Answer 25

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

Question 26

What is Charcot’s foot?

Answer 26

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.