Professional Documents
Culture Documents
Ulcer
Ulcer
Introduction
• An ulcer is a break in the continuity of the covering epithelium,
either skin/mucous membrane due to molecular death.
• Part of an ulcer
1. Margin
• It may be regular/irregular.
• It may be rounded/oval.
2. Edge
• Edge is the one which connects floor of the ulcer to the margin.
• Different edges are :
Introduction
Sloping edge
• It is seen in a healing ulcer.
• Its inner part is red because of red, healthy granulation tissue.
• Its outer part is white due to scar/fibrous tissue.
• Its middle part is blue due to epithelial proliferation.
Undermined edge
• It is seen in a tuberculous ulcer.
• Disease process advances in deeper plane (in subcutaneous tissue)
whereas (skin) epidermis proliferates inwards.
3. Floor
• It is the one which is seen.
• Floor may contain discharge, granulation tissue/slough.
4. Base
• Base is the one on which ulcer rests.
• It may be bone/soft tissue.
Introduction
• Induration of an ulcer
• Induration is a clinical palpatory sign which means a specific type
of hardness in the diseased tissue.
• It is obvious in well-differentiated carcinomas.
• It is better felt in squamous cell carcinoma.
• It is also observed in long standing ulcer with underlying fibrosis.
• It is absent/less in poorly differentiated carcinomas & malignant
melanoma.
• Less indurated carcinoma is more aggressive.
Introduction
• Induration of an ulcer
• Specific types of indurations are observed in venous disease &
chronic deep venous thrombosis.
• Brawny induration is a feature of an abscess.
• Induration is felt at edge, base & surrounding area of an ulcer.
• Induration at surrounding area signifies the extent of disease
(tumor).
• Outermost part of the indurated area is taken as the point from
where clearance of wide excision is planned.
Classification
• Classification 1 (clinical)
1. Spreading ulcer
• Here edge is inflamed, irregular & edematous.
• Classification 3 (pathological)
1. Specific ulcers
• Tuberculous ulcer
• Syphilitic ulcer – It is punched out, deep, with “wash-leather” slough in
the floor & with indurated base.
• Actinomycosis
• Meleney’s ulcer
Classification
2. Malignant ulcers
• Carcinomatous ulcer
• Rodent ulcer
• Melanotic ulcer
• Bazin’s ulcer
• Diabetic ulcer
Classification
• Ulcers due to leucaemia, polycythemia, jaundice, collagen diseases,
lymphoedema.
• These ulcers are callous ulcers last for long time & require excision &
skin grafting.
Wagner’s Grading/classification of ulcer
• Types
• Healthy granulation tissue
• It occurs in a healing ulcer.
• It has got sloping edge.
• It bleeds on touch.
• It has got serous discharge.
• 5 Ps of granulation tissue – Pink, punctate hemorrhages, pulseful,
painless, pin head granulation.
• Skin grafting takes up well with healthy granulation tissue.
• Streptococci growth in culture should be less than 105/gram of tissue
before skin grafting
Granulation tissue
• Unhealthy granulation tissue
• It is pale with purulent discharge.
• Its floor is covered with slough.
• Its edge is inflamed & edematous.
• It is a spreading ulcer.
• Pyogenic granuloma
• It is a type of exuberant granulation tissue.
• Here granulation tissue from an infected wound/ulcer bed protrudes
out, presenting as a well-localised, red swelling which bleeds on
touching.
• Differential diagnosis – Papilloma, skin adnexal tumors.
• Treatment – Antibiotics, excision & sent for biopsy.
Granulation tissue
• Different discharges in an ulcer (as well as from sinus)
a. Serous – In healing ulcer
b. Purulent - In infected ulcer
c. Bloody – Malignant ulcer, healing ulcer from healthy granulation
tissue
d. Seropurulent
e. Serosanguinous – Serous & blood
f. Serous with Sulphur granules – Actinomycosis
g. Yellowish – Tuberculous ulcer
Investigations for an ulcer
• Study of discharge – Culture & sensitivity, AFB study, cytology.
• Wedge biopsy – Biopsy is taken from the edge because edge contains
multiplying cells.
• Usually 2 biopsies are taken.
• Biopsy taken from the center may be inadequate because of central
necrosis.
• X-ray of the part to look for periostitis/osteomyelitis.
• FNAC (Fine needle aspiration cytology) of the lymph node.
• Acriflavine is antiseptic & irritant & so desloughs the area & promotes
granulation tissue formation.
• Maggots if present in the wound will cause crawling sensation & are
removed using turpentine solution.
• Sterile foam is placed over the ulcer bed covering widely, tube drain
with multiple holes is kept within it & end of the tube comes out
significantly away, foam is sealed airtight using a sterile adhesive film.
Management of an ulcer
• Tube is connected to suction system.
• Maggots are larvae of the green bottle fly, also known as the green
blowfly (Lucilia sericata).
• They act by dissolving & engulfing dead necrotic tissues, they may
reduce the bacterial content in the wound.
• Paraffin dressing
• Local causes
• Recurrent infection
• Trauma, presence of foreign body/sequestrum
• Absence of rest & immobilization
• Poor blood supply, hypoxia
• Edema of the part
• Loss of sensation
• Periostitis/osteomyelitis of the underlying bone
• Fibrosis of the surrounding soft tissues
• Lymphatic diseases
Causes of formation of chronic/nonhealing ulcer
• General/specific causes
• Anemia, hypoproteinemia
• Vitamin deficiencies
• Tuberculosis, leprosy
• Diabetes mellitus, hypertension
• Chronic liver/kidney diseases
• Steroid therapy locally/systemically
• Cytotoxic chemotherapy/radiotherapy
• Malignancy
Traumatic ulcer
• It may be mechanical – dental ulcer along the margin of the tongue due
to tooth injury; physical - like by electrical burn; chemical - like by alkali
injury.
• Blood flow to the skin stops once external pressure becomes more
than 30 mmHg (more than capillary occlusive pressure) & this causes
tissue hypoxia, necrosis & ulceration.
• It is due to:
• Impaired nutrition
• Defective blood supply
• Neurological deficit
Trophic ulcer (pressure sore/decubitus ulcer)
• Sites
• Over the ischial tuberosity
• Sacrum
• In the heel
• In relation to heads of metatarsals
• Over the shoulder
• Occiput
• Investigations
• Study of discharge, blood sugar, biopsy from the edge, X-ray of the part,
X-ray spine.
Staging of pressure sore
• Full thickness skin loss extending into subcutaneous tissue but not
through fascia – early deep ulcer
• Full thickness skin loss with fascia & underlying structures like
muscle/tendon/bone etc. – late deep ulcer
Treatment
• Negative pressure reduces tissue edema, clears the interstitial fluid &
improves the perfusion, increases the cell proliferation & so promotes
the healing.
• A perforated drain is kept over the foam dressing covered over the
pressure sore.
Treatment
• Proper care
• Change in position once in 2 hours
• Lifting the limb upwards for 10 seconds once in 10 minutes
• Nutrition
Treatment
• Use of water bed/air bed/air fluid floatation bed & pressure dispersion
cushions to the affected area;
• Urinary & fecal care
• Hygiene
• Psychological counselling.
• Regular skin observation
• Keeping skin clean & dry (using regular use of talcum powder)
• Oil massaging of the skin & soft tissues using clean, absorbent porous
clothing
• Control & prevention of sepsis helps in the management.
Ulcer due to chilblains
• It is due to exposure of a part to wet cold below the freezing point (cold
wind).
• There is arteriolar spasm, denaturation of proteins & cell destruction.
• It leads to gangrene of the part.
• Ulcers here are always deep.
Martorell’s Ulcer (1945)
• Treatment
• Once ulcer granulates well, skin grafting with lumbar sympathectomy is
done.
Arterial/ischemic ulcer
• It is common in toes, feet/legs; often can occur in upper limb digits.
• Management
• Specific investigations like arterial doppler, angiogram, lipid profile &
blood sugar are done.
• Treatment is done accordingly drugs like vasodilators, arterial surgeries
may be needed.
Bairnsdale ulcer
• It is chronic, irregular, undetermined ulcer due to Mycobacterium
ulcerations infection.
• Hard, discrete regional lymph nodes are often palpable, initially mobile
but later become fixed.
• Ulcer & lymph nodes are initially pain-less; but becomes painful &
tender once there is deeper infiltration/secondary infection.
• Management
• Wedge biopsy ▲; FNAC of regional lymph nodes are the investigations.
• Treated with wide local excision with skin grafting & regional lymph
node block dissection.
Marjolin’s ulcer (Rene Marjolin, 1828, Paris)
• Lesion is ulcerative/proliferate.
• Once lesion spreads into adjacent normal skin, it can spread into
regional lymph nodes behaving like squamous cell carcinoma.
• Ulcer shows central area of dry scab with peripheral raised active &
beaded (pearly white) edge.
• It erodes into deeper plane like soft tissues, cartilages & bones hence
the name – rodent ulcer.
• Management
• Wedge biopsy, CT scan of the part to see the depth, wide excision.
Melanotic ulcer
• It is ulcerative form of melanoma.
• It can occur in skin as de novo/in a pre-existing mole.
• Ulcer is pigmented often with a halo around.
• Ulcer is rapidly growing, often with satellite nodules & ‘in-transit’
lesions.
• It is very aggressive skin tumor arising from melanocytes.
• It spreads rapidly to regional lymph nodes which are pigmented.
• Blood spread to liver, lungs, brain & bones is common.
• It can occur in mucosa, genitalia & eye.
• It is a systemic malignant disease.
Melanotic ulcer
• Management
• Excision biopsy (usually incision biopsy is not done), FNAC lymph node,
US abdomen.
• Causes
• Increased glucose in the tissue precipitates infection.
• Diabetic microangiopathy which affects microcirculation.
• Increased glycosylated hemoglobin decreases the oxygen dissociation.
• Increased glycosylated tissue protein decreases the oxygen utilization.
• Diabetic neuropathy involving all sensory, motor & autonomous
components.
• Associated atherosclerosis.
Diabetic ulcer
• Diabetic angiopathy may be macro-angiopathy (thickening of the
basement membrane of vessels & capillaries).
• Sepsis in diabetes
• Cellulitis, deep seated abscess, ulcer formation, gangrene foot,
osteomyelitis of metatarsals, septicemia, multiorgan dysfunction
syndrome can occur faster in diabetes.
• Sites
• Foot-plantar aspect – is the most common site
• Leg
• Upper limb, back, scrotum, perineum
• Diabetic ulcer may be associated with ischemia
• Ulcer is usually spreading & deep
• Investigation
• Blood sugar both random & fasting
• Urine ketone bodies
• Discharge for culture & sensitivity
• X-ray of the part to see osteomyelitis.
• Arterial Doppler of the limb; glycosylated hemoglobin estimation
Diabetic ulcer
• Treatment
• Control of diabetes using insulin.
• Antibiotics
• Nutritional supplements
• Regular cleaning, debridement, dressing
• Once granulates, the ulcer is covered with skin graft/flap.
• Revascularization procedure is done by
endarterectomy/thrombectomy/balloon angioplasty/arterial bypass
graft.
• But if distal vessels are involved then success rate is less.
• Toe/foot/leg amputation
• Microcellular rubber (MCR) shoes to prevent injuries; care of foot.
Meleney’s ulcer (postoperative synergistic gangrene)
• Etiology
• It is common in old age & immunosuppressed individuals & after
surgery for infected cases.
• Sites
• It is common in abdomen & thorax.
• It begins in wound margin & spreads rapidly.
• It can also occur in other areas of skin.
• Infection is severe, often with endarteritis of the skin leading to ulcer &
destruction.
Meleney’s ulcer (postoperative synergistic gangrene)
• Clinical features
• Features of toxemia.
• Spreading painful ulcer with discharge.
• Abundant granulation tissue with purple & red zones.
• Management
• Random blood sugar is checked, if diabetic it has to be controlled.
• Antibiotics
• Blood transfusion, critical care.
• Adequate excision of dead tissues until it bleeds.
• Once healthy granulation tissue is formed skin grafting is done.
Lupus vulgaris (‘Lupus’ wolf)
• The ulcer is active & destruction occurs at the periphery with healing
takes place at the center.
• Often lesion extends into nose & oral cavity involving the mucosa.
Lupus vulgaris (‘Lupus’ wolf)
• Investigation
• ESR, discharge study, biopsy, chest X-ray.
• Treatment
• Anti tuberculous drugs
• If complete healing does not occur, then excision & skin grafting is
required.
Tuberculous Ulcer
• It is usually due to cold abscess later forming ulcer in the neck, chest
wall, axilla & groin.
• Management
• Discharge study for epithelioid cells (modified histiocytes), AFB, edge
biopsy, anti tuberculous drugs.
Bazin’s disease (Erythrocyanosis frigida/Erythema induratum)
• Bluish pink leg which becomes bluish mottling in extreme cold season.
• On warming, skin turns bright red & painful which is typical due to
hyperemia.
Bazin’s disease (Erythrocyanosis frigida/Erythema induratum)
• Symmetrical, purple nodules develop in ankles & lower leg which later
break down forming multiple, small, painful, superficial ulcers often with
ankle edema & pigment scars.
• Spreading stops in few weeks with ulcer persisting for many months to
years.
• Treatment
• Improvement in nutrition, penicillin, metronidazole, Eusol dressing, skin
grafting at a later date.
Venous ulcer (gravitational ulcer)
• 50% of venous ulcer are due to varicose veins; 50% are due to post
phlebitis limb (previous DVT).
Venous ulcer (gravitational ulcer)
• Venous ulcer is vertically oval with sloping edge & will not penetrate
deep fascia.
• Ulcer often attains very large size which is nonhealing, indolent &
callous.
• This unstable scar of long duration may lead into squamous cell
carcinoma (Marjolin’s ulcer).
Venous ulcer (gravitational ulcer)
• Management
• Venous Doppler, regular dressing, skin grafting, specific treatment for
varicose veins.
Syphilitic ulcer
• Shotty painless, firm, discrete groin lymph nodes may get enlarged along
with genital chancre.
• Also there appears raised, flat, hypertrophied & warty like epithelium at
mucocutaneous junctions (mouth, genitalia) called as condyloma lata.
• Epitrochlear nodes are felt 1-2 cm above the medical epicondyle (It is
also enlarged in non-Hodgkin’s lymphoma/NHL).
Syphilitic ulcer
• Iritis, arthritis, hepatitis (massive liver in syphilis is called as hepar
lobatum), meningitis, syphilitic osteitis with ‘ivory’ sequestrum, coppery
red skin rash, moth-eaten alopecia are other features of 2nd syphilis.
• It is also can occur over the tongue, anterior aspect of the scrotum.
• It is due to delayed hypersensitivity reaction with endarteritis obliterans
& vasculitis.
Syphilitic ulcer
• Perforation of nasal septum/palate can occur.
• Clutton’s joint & Sabre tibia are often seen.
• Lymph nodes are not affected in tertiary syphilis.
• These multiple irregular genital ulcers appear 3 days after infection with
Hemophilus ducrey’s as a venereal disease.
• Frei intradermal test becomes positive in 6 weeks & remains positive for
life time.
Climatic bubo/tropical bubo
• In tertiary stage, eye, joint, meninges may get involved after many years.
• Ulcer can occur, in various parts like over shin, legs, feet, face, chest
wall, in various disease like anemia, polycythemia, sickle cell disease,
hereditary spherocytosis, leukemia, vasculitis, autoimmune disease, like
RA, Paget’s disease of bone (deep, nonmobile, fixed to bone; common
in tibia), ulcerative colitis, etc.
• Poor hygiene & dressings can cause multiple, small, red often scabbed
staphylococcus aureus ulcers on the skin over the leg & feet which is
often recurrent & disturbing.
Other ulcer