ULCERS

- An ulcer is a discontinuity of an epithelial surface.

- It is characterized by progressive destruction of the surface
epithelium and a granulating base.
- Ulcers can be classified as non-specific, specific and malignant.

ulcer type
peptic Non specific
Pressure sores (Decubitus ulcers) and Non specific
ischemic ulcers
Gravitational ulcers: Venous Non specific
insufficiency
Secondary infective: wound infection Non specific
and abscess drainage
Traumatic ulcers Non specific
Neuropathic ulcers: D.M. , leprosy Non specific

Iatrogenic: Intravenous fluid Non specific

extravasation
Dermatitis artefacta Non specific
Aphthous Non specific
Primary infective: herpes simplex- Specific
tuberculosis- fungal- syphilis
Gastro intestinal tract and skin Malignant

‘Classification of common types of ulcers’

 - An ulcer has edge, base, floor and margin.

- The edge of an ulcer is the most important feature

because it is the junction between healthy and diseased tissue
and takes a characteristic form according to the underlying
pathology.
- There are five common types of ulcer edge:
 Sloping edge:
The edge slopes gently from the normal skin to the base of
the ulcer. It is pale pink and consists of new, healthy
epithelium growing in over the base of the ulcer. The best
examples are healing ulcers, traumatic, ischemic and
venous ulcers.

 Punched out edge:

The edge drops down at right angles to the skin surface to
make the ulcer looks as it has been cut out of the skin
with a punch. It indicates a localized, usually full
thickness, area of skin loss surrounded by healthy tissue.
The best example is the trophic ulcer.

 Undermined edge:
The disease causing this type of edge spreads in and
destroys the subcutaneous tissues faster than it destroys the
overlying skin. The overhanging skin is usually reddish
blue, friable and unhealthy. Tuberculous ulcers always
have undermined edges.

 Rolled edge:
A rolled ulcer edge develops when an invasive cellular
disease becomes necrotic at its centre but grows quickly at
the periphery, so that it rises above the skin surface. A
‘rolled’ edge is typical for basal cell carcinoma.

 Everted edge:
When an ulcer is caused by a fast growing infiltrating
disease. This appearance is typical of squamous cell
carcinoma and ulcerated adenocarcinoma.
Sinus versus Fistula:
Sinus:
- A sinus is a blind ending tract that connects a cavity lined
with granulation tissue (often an abscess cavity) with an
epithelial surface.
- Sinuses may be congenital or acquired.
- Congenital sinuses arise from the remnants of embryonic
ducts that persist instead of being obliterated and involuted
during embryonic development.
- Acquired sinuses occur as a result of the presence of a
retained foreign body (e.g. suture material), specific chronic
infection (e.g. Tuberculosis), malignancy or inadequate
drainage of the cavity.
- Treatment of the sinus is directed at removing the underlying
cause.
- Biopsies should always be taken from the wall of the sinus to
exclude malignancy or specific infection.

Congenital sinuses Acquired sinuses

Pre-auricular Pilonidal

Umbilical Suture

Urachal T.B.

Coccygeal Osteomyelitis

sacral Crohn’s disease

Fistula:
- A fistula is an abnormal communication between two
epithelium lined surfaces.
- This communication or tract may be lined by granulation
tissue but may become epithelialized in chronic cases.
- Fistulas may be congenital or acquired.
- Management of the fistula is directed to treating the
underlying cause.

Congenital fistulas Acquired fistulas

Tracheo-esophageal Entero-cutaneous

Branchial Arteriovenous (A-V fistula):

- Traumatic
- Iatrogenic (for
haemodialysis in renal failure
patients)

(a) a sinus (b) a fistula

Causes of ulceration of skin of the lower limb:
1. Venous: 60% (half varicose and half post thrombotic)
2. Ischemia: 20% (one quarter have an associated venous
pathology)
3. Collagen disease: 5% (rheumatoid and systemic lupus
erythrematosus)
4. Neuropathic: 2%
5. Traumatic: 1%
6. Neoplastic: 1%
7. Rare causes: 5%
8. Unknown causes: 10%

 Venous ulcers are found in the lower medial third of the lower
limb. Their site is a diagnostic feature.
 Arterial insufficiency is usually manifest at the ends of the
limbs. It is rare to see ulcers caused by arterial disease at the
base of the limbs or on the trunk.
 Trophic ulcer is an ulcer which has developed as a result of the
patient’s insensitivity to repeated trauma. Those ulcers are
commonly associated with forms of neurological disease which
cause loss of appreciation of pain and light touch in weight
bearing areas.

‘Venous ulcer’