T3: Chronic Leg Ulcer Flashcards
What is an ulcer?
Ulcer: It is a local defect, or excavation of the surface of an organ or tissue that is produced by sloughing of inflammatory necrotic tissue. It is the loss of epidermis.
What is the difference between an ulcer and an erosion?
In the context of the skin, an ulcer is the loss of an area of the epidermis and dermis. In an erosion there is only loss of the epidermis. An erosion is quite shallow. It can be quite deep, it can reach the muscle or tendon.
What are causes of leg ulcer?
The most common cause is vascular (90%) - of this venous causes make up 70%, arterial 10% and the other 10% is a mixed caused.
The remaining 10% is other rarer causes. These include:
• Neuropathic – peripheral neuropathy
• Inflammatory – pyoderma gangrenosum, morphoea, necrobiosis lipoidica
• Malignant – Squamous cell carcinoma, Basal cell carcinoma, - these are carcinomas, lymphoma
• Vascular – vasculitis and CTD, occlusive disease
• Iatrogenic – pressure sores, drugs (hydroxyurea, warfarin necrosis, nicorandil)
• Infection – bacterial, fungal
• Metabolic – diabetes mellitus, calcinosis cutis (condition where ether is deposition of calcium in the skin. Seen when the skin is damaged or inflamed promoting calcium deposition even in patients with normal serum calcium levels or in patients with disordered metabolic and phosphate and having hypercalcaemia).
• Traumatic - (accidental/self induced/DA), Burns (chemical, electrical, thermal, radiation)
What are risk factors for venous ulcers?
- Valvular incompetence (primary or secondary) e.g. primary varicose veins or secondary damage. The veins do not work effectively and so blood does not pump up as effectively, leading to pooling of blood and venous HTN. Breakdown products of blood then deposit in the skin.
- Previous damage to venous system (DVT, hypertension, peripheral oedema)
- Obesity, (increased subcutaneous tissue pressing on the venous return, this is also why pregnant women are more at risk).
- Immobility (poor muscle contraction -> venous pooling and hypertension). You should therefore investigate someone with unilateral leg odema for inguinal lymphopathy (pelvic malignancy).
What are clinical examination findings of venous leg ulcer?
Typically the medial gaiter area (i.e. area extending from just above the ankle to below the knee and tends to occur on both lateral and medial aspect of the leg) most common site of leg ulcer. Venous ulcers don’t tend to be painful, but arterial ones tend to be. Tend to be quite superficial, sloughy with ill defined borders. Associated signs of chronic venous hypertension. Brown backwound, hemosiderin deposition - breakdown products of blood being deposed in the skin. People can then get venous eczema as they irritate the skin - causing itching, inflammation etc.
What is Bilateral erythema?
Erythema is a type of skin rash caused by injured or inflamed blood capillaries. It usually occurs in response to a drug, disease or infection. Rash severity ranges from mild to life threatening. This therefore occurs on both legs in bilateral cellulitis. This almost never exists. Must think about bilateral venous changes and a background of eczema.
What is lipodermatosclerosis?
Lipodermatosclerosis refers to changes in the skin of the lower legs. It is a form of panniculitis (inflammation of the layer of fat under the skin). It is characterised by subcutaneous fibrosis and hardening of the skin on the lower legs.
What are associated signs of chronic venous hypertension?
- Venous flare - thread veins seen on the ankle area on the dorsum of the foot.
- Varicose eczema is the body reacting to the hemosiderin deposition causing breakdown and skin and an itch. If not treated with strong ointments and steroids, can lead to susceptibility of bacterial infections.
- Lipodermatosclerosis
- Atrophie blance
These two are scarring patterns and inflammation and fibrosis in the dermis due to venous HTN which induces inflammation. A cytokine storm causes constriction of the skin and dermal fibrosis. “Inverted champagne bottle.”
What are causes of arterial leg ulcers?
Risk factors - any/all that cause cardiovascular/peripheral vascular disease:
• Diabetes
• Smoking
• High blood lipids
• High blood pressure
• History of ischaemic heart disease, cerebrovascular disease or peripheral vascular disease
• Renal failure
• Obesity
• Rheumatoid arthritis - here the most common cause of death is CVD. The proinflammatory disease, and psoriasis have an increased risk of arterial disease.
• Clotting and circulation disorders
What are history findings of arterial leg ulcer?
- Rest pain or paraesthesia
- Pain at the ulcer site
- Other symptoms of vascular disease e.g. angina
- Intermittent claudication
What are clinical examination findings of arterial leg ulcer?
occur in lower leg/foot. This is it is the most gravity dependent area.
• Have cold skin
• Loss of hair appendages
• Dry skin
• Cool peripheries
• Pale or cyanotic(dusky) or pre-gangrenous toes
• Position dependent ischaemia (pallor if leg raised = Buerger’s sign)
• Reduction in proximal and or peripheral pulses (ABPI) +/- bruit
5 P’s of PVD - Pale, pulseless, paraesthesia, painful and paralysis
What are clinical examination findings of neuropathic leg ulcer?
- Due to distal polyneuropathy (motor/sensory/autonomic)
- Under metatarsal heads / heel - punched out areas
- Painless but warm with pulses - the patienst may not be aware. This is why diabetic foot clinics are so important.
What are causes of neuropathic leg ulcer?
Causes: • Diabetes • Other causes of polyneuropathy ○ Alcohol,B1/B12 deficiency Charcot Marie Tooth
○ A rare cause is Pyoderma Gangrenosum
What is healing by first intention?
These are typically clean cut wounds - the ends of the epidermis are close together. Typically lactations where there is not much tissue lost, surgical incisions etc.
Initially there is exudation and fibrin clot. Over time in the dermis there is synthesis of collagen in scar formation and the epidermis regenerations.
What is healing by second intention?
Wounds with tissue loss or wounds with non-opposed margins heal like this e.g. ulcer. The red spots is granulation tissue - consists of proliferating capillaries, surrounding by fibrous cells and inflammatory cells. In healing there is granulation islands and re-epithelisation of the tissue.
