Skin ulcers

Question 1

Etiology

Answer 1

Venous
Arterial->large or small vessel
Neuropathic
Lymphoedema
Vasculitis
Malignancy
Infection->TB, Syphillis
Trauma, pressure
Pyoderma gangrenosum
Drugs

Question 2

Most common cause

Answer 2

Venous disease 70%

Question 3

HISTORY

Answer 3

1. Number
2. Pain
3. Trauma
4. Co-morbidities: varicose, PAD, diabtese, HTN, lipids, smoking, vasculitis, skin cancer, TB risks, syphillis, claudication, RA, IBD
5. Long term or short
6. Steroids? Immunosuppressants
7. Self induced?
8. Has a biopsy been taken
9. What have they tried
10. Pallor, cold, relieved by dependant position, blackened
11. Dermatitis, discolouration, oozing, wet, bleeds easily

Question 4

Examination

Answer 4

1. Ulcer
Position
Edge
Base
Necrosis
Slough
Erythema
2. Comorbidities
Cardiovascular
PAD
Diabetes

Question 5

Punched out, squared edges

Answer 5

Ischemic
Black, dry, tender base, necrotic
Painful

Question 6

Flat, sloping edges, sloughy, edematous, infected

Answer 6

Pressure
Neuropathic
Venous

Question 7

Location of neuropathic

Answer 7

Digits
Pressure points
Xray to exclude bone involvement

Question 8

Raised, everted

Answer 8

Maligneant
Fixed
Bloody, infected, necrotic
Lymphadenopathy

Question 9

Investigations

Answer 9

Biopsy may be necessary
Assess for vasculitis
Screening for suspected systemic if indicated
FBC
CRP/ESR, RF, ANA, ANCA, complement if suspect vasculitis
ABPI
UEC
Glucose
Lipids
If deep, overlies bone-> Xray
Swab->need more clinical findings than positive culture before treating with antibiotics

Question 10

Management

Answer 10

1. Treat underlying cause: glucose, lipids, revascularisation
2. Treat any infection
3. Venous ulcers->compression bandages
4. Relieve pressure with neuropathic, orthoses
5. Keep clean and moist, avoid dressings sticking
6. Optimise nutrition
7. Expert nursing care

Question 11

Preventing development of neuropathic

Answer 11

limited joint mobility of the foot and ankle, calluses,

bunions, hammer toes, claw toes

Question 12

How does diabetes +risk of ulcers

Answer 12

These include motor neuropathy leading to
muscle atrophy, altered biomechanics, and foot deformities; sensory neuropathy that increases susceptibility to injuries; and autonomic neuropathy leading to decreased
sweating, skin dryness, cracks, and increased susceptibility to infections

Question 13

Charcot neuroarthropathy

Answer 13

Non-infective destruction of bone from repeated trauma to insensate area
Difficult to differentiate from osteomyelitis when overlying ulcer